NEW GRADUATE NURSES' PERCEPTION OF THE WORKPLACE: HAVE THEY EXPERIENCED BULLYING? DARLA A. VOGELPOHL, PHD, MSN, CNS, RN,⁎ SUSAN K. RICE, PHD, RN, CPNP, NCSN,† MARY ELLEN EDWARDS, PHD,† AND CHRISTOPHER E. BORK, PHD† This study investigated the bullying experience in the workplace of newly licensed registered nurses (RNs). Preventing newly licensed nurses from leaving the profession is important, especially because there is a nursing shortage. Education of staff and administrators provides recognition of negative behaviors in the workplace. Participants in this research study included 135 newly licensed RN's from 5 nursing schools in Northwestern Ohio licensed in years 2007–2010. Quantitative methods and a descriptive design process included chi-square tests and descriptive statistical methods. Bullying workplace behaviors were identified by participants utilizing the survey tool, the Negative Acts Questionnaire–Revised, and a questionnaire on work relationships and bullies recognized in the workplace. Nursing peers, physicians, or a patient's family were the main sources of bullying, and 29.5% had considered leaving the nursing profession. Education of staff is imperative for providing recognition of negative behaviors in the workplace. Bullying occurs in the workplace and is affecting the new graduates' work performance. Retaining newly graduated nurses is the ultimate goal for maintaining RN's in the workforce. (Index words: Workplace bullying; Bullying; New graduate nurses) J Prof Nurs 29:414–422, 2013. © 2013 Elsevier Inc. All rights reserved.
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EGISTERED NURSES (RNS) ARE increasingly in high demand in health care organizations to care for acutely ill patients, yet a significant numbers of RNs leave the profession within a few years of graduating. Research indicates that 30%–60% of new graduate nurses actually leave or intend to leave their nursing jobs after 6 months to 1 year (Bowles & Candela, 2005; Bartholowmew, 2006; Simons, 2008). Among various reasons for this, it is suspected that a hostile work environment, more specifically bullying in the workplace, may contribute to RNs leaving their jobs and profession (Johnson & Rea, 2009; Simons, 2008; Bartholowmew, 2006, Bowles & Candela, 2005). Recommendations from professional organizations (American Nurses Association [ANA], 2003; The Joint Commission [JCAHO], 2008) call for participation of ⁎Assistant Professor, The University of Toledo, Toledo, OH. †Professor, The University of Toledo, Toledo, OH. Address correspondence to Dr. Vogelpohl: The University of Toledo, College of Nursing, Health Science Campus, Mail Stop 1026, 3000 Arlington Ave., 3213 Collier Building, Toledo, OH 43614. E-mail: [email protected] 8755-7223/12/$ - see front matter 414 http://dx.doi.org/10.1016/j.profnurs.2012.10.008
leaders/managers in skill-based training to focus on unprofessional employee behavior and conflict resolution. Workplace bullying has been described as a persistent, enduring form of abuse that involves negative actions and interactions at work (Lutgen-Sandvik, Tracy, & Alberts, 2007). There are catastrophic results for both the organization and the target of bullying of this current and prevalent workplace dilemma (Einarsen, Hoel, Zapf, & Cooper, 2003; Rayner & Keashly, 2005). Statistics project the crisis in health care that is occurring as the result of the nursing shortage and replacement costs for the health care organization and consumers. The U.S. Bureau of Labor Statistics (2007) has projected that more than 1 million replacement nurses will be needed to accommodate health care needs in the United States by 2016 (U.S. Department of Health and Services, 2007). A hospital with a poor nursing retention rate could spend annually an average of $3.6 million more than a hospital with a good nursing retention rate (PricewaterhouseCoopers' Health research Institute, 2007). The victims of workplace bullying can be very costly to health care organizations (the Workplace Bullying Institute, 2010). Lawsuits are pursued by some employees to seek justice against the aggressor or
Journal of Professional Nursing, Vol 29, No. 6 (November/December), 2013: pp 414–422 © 2013 Elsevier Inc. All rights reserved.
NEW GRADUATE NURSES' PERCEPTION OF THE WORKPLACE
organization, and the litigation and settlements cost up to $1.4 million. They project that a Fortune 500 Company could spend up to $24,000,000 annually between staff turnover and lost productivity. In addition, as a result of abusive behavior among staff, patients were also found to be at a 20% more risk of harm from professionals in the Silence Kills (2005) study. Bullying in the workplace is costly financially for the health organization and is a destructive force in human relationships. Longo and Sherman (2007) summed the personal effects of horizontal violence. Nurse victims experience powerlessness and eventually experience the following health problems as a result of horizontal violence: (a) insomnia, (b) low self-esteem, (c) low work morale, (d) disconnection from others, (e) depression, and (f) usage of more sick leave than the nurse not involved in horizontal violence. The overall purpose of this study was to investigate the bullying experience of the newly graduated RN. Workrelated bullying, person-related bullying, and physically intimidating bullying are the three factors identified as negative work experiences (Einarsen, Hoel, & Notelaers, 2009) using the (Negative Acts Questionnaire–Revised [NAQ-R]) survey tool. The purposes of this study were to find if the newly graduated RN experienced these types of bullying, determine the relational affects bullying has on the newly graduated RN, and determine who does the bullying.
Literature Review In the 1960s, workplace harassment in the United States revolved mainly around sexual and racial harassment cases. The Title VII Civil Rights Act of 1964 provided legal grounds to stop harassment issues and prevent discriminatory practices of employers to their employees. Workplace bullying is a recently identified form of harassment that is being studied more intensely in the United States during the past decade. During the last two decades, most of the workplace research has been done in European countries, the United Kingdom, and Australia (Dellesega, 2009). In the United States, there is one major U.S. workplace study on various professions (Lutgen-Sandvik et al., 2007) and a few U.S. studies in the nursing profession (Johnson & Rea, 2009; Simons, 2008; Bowles & Candela, 2005; Bartholowmew, 2006; Griffin, 2004). The newly licensed nurse chose to leave the nursing profession because of problems in the work environment in one U.S. study. The survey involved 352 RNs who graduated from a basic nursing program in NV, USA (Bowles & Candela, 2005). As a result of a negative work environment, these authors reported that 30% of new nurses left their job within the first year, and 57% left by the second year. In Bartholowmew's (2006) study, 60% of RNs in the United States were found to leave their first position within 6 months because of horizontal violence. Ninety to 97% of nurses reported verbal abuse from physicians.
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Simons (2008) did the first U.S. study on nurses in the workplace using the NAQ-R (Einarsen & Hoel, 2001). The study determined that workplace bullying was experienced by newly licensed RNs within 6 months of employment after becoming an RN. Simons' study determined if RNs intended to leave the organization as a result of being bullied. Thirty-one percent of the participants in Simons' study did relate their experience of being bullied in the workplace, which was interpreted as a major determinant of their intent to leave the organization. Using the operational definition of the NAQ-R survey, bullying consisted of at least two bullying behaviors on a weekly or daily basis occurring during the past 6 months. Bullying was found to be higher in this study than those in other international studies previously done using the NAQ-R and using this operational definition of bullying. The seriousness of disruptive nursing behavior is summarized by JCAHO (2008) that released Sentinel Alert 40, requiring health care facilities to ensure that health care organizations design an organizational approach to make employees aware of bullying and disruptive behaviors (The Joint Commission news release). Harmful behaviors between staff that are rude and hostile are threatening to the provision of quality patient care and prompted JCAHO to address them in accreditations of health organizations. Statistics of the JCAHO (2008) survey found that 50% of nurses had been a victim of bullying and/or disruptive behavior in the workplace, and 90% stated that they witnessed others being the brunt of abuse within their organization. Einarsen (1999) is one of the major researchers in the area of workplace bullying. His group, the Bergen Bullying Research Group at the University of Norway, has been studying bullying for years and developed survey instruments to collect data. Einarsen and Hoel (2001) explain that workplace bullying is a situation where a person feels mistreated because they are persistently exposed to interpersonal aggression over a long period. Dealing with interpersonal aggression can have a devastating effect on the person and organization in which they work.
Concepts and Definitions Bullying is the persistent act of demeaning and downgrading another person through cruel words and negative actions that undermine another's self-confidence and self-esteem (Adams, 1997). Bullying, a growing problem in society, involves maltreatment of one person, the victim, by another person(s), and the bully (Einarsen & Hoel, 2001) and includes the aggressors' tactics of offending behaviors, harassment, and/or social exclusion. In addition, bullying is described as repeated incidents (e.g., once/week) and for a certain amount of time (e.g., 6 months). A single occurrence with two opposing persons having a single conflict does not constitute bullying (Zapf & Gross, 2001). The bullying conflict is difficult to resolve because there is often a power disparity between the
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bully and victim. The bullying on the surface appears nonaggressive, which makes it difficult for a victim to speak out about the aggression (Lutgen-Sandvik et al., 2007; Leymann, 1996, Zapf & Gross, 2001). Workplace bullying is distinct from other definitions such as incivility or disruptive behaviors because the behaviors of the bully toward the victim are not random acts, are intentional, and occur over an extended period. Workplace incivility is defined as disrespectful deviant work behaviors of a person to harm another that violates workplace rules (Andersson & Pearson, 1999. In addition, uncivil behaviors are generally discourteous and rude and demonstrate the lack of mutual respect in the workplace. Most of the cases of workplace bullying are negative psychological acts. Issues may involve work issues (e.g., withholding information needed in a job) or nonwork issues (e.g., humiliating and insulting acts), and the victim has difficulty defending himself or herself (Einarsen, Raknes, & Matthieson, 1994; Leymann, 1996). The perpetrator has no intention to stop the bullying tactics directed toward the victim in workplace bullying (Hubert, Furda, & Steensma, 2001). The intent of this research study using the NAQ-R and relational questionnaire was to determine if new graduate nurses recognized bullying tactics, were bullied as a newly licensed RN, intended to leave nursing, identified the bullies in the workplace, and received education/ support from employers.
Method This descriptive research study surveyed a convenience sample of newly licensed RNs' perception of bullying occurrence in the workplace. The main characteristics included the sampling of the newly licensed RN population, and information was collected through an electronic survey. Bullying behaviors in the workplace were identified utilizing the survey tool, the NAQ-R, the “New Graduate Nurses Relational Questionnaire,” and questions identifying the bully in the workplace.
Sample Population A survey design was implemented to determine the perceptions of the new graduate nurse RN regarding bullying in the workplace. This research study was submitted to the institutional review board for review. The questionnaire was sent electronically to the target population, 2,079 newly licensed alumni nurses from 2007 to 2010. Five Northwest Ohio Colleges of Nursing Alumni Associations were included in the electronic email survey. Three mailings at 1–2 weeks after the initial e-mail were sent to get the maximum return rate. The single random sample size was set with a confidence level of 95% (α = .5) and the total tolerated reduction error of no more than plus or minus 5% (Backstrum & HurshCesar, 1981). Of the 2,079 participants who were sent the survey, 135 (7%) of newly licensed nurses responded. Participants were informed that privacy and confidentiality were incorporated within the data collection
process, and only one person at the institutional research center had access. The survey data submitted were gathered using Vovici software.
Survey Instrument The survey instrument, the NAQ-R (Einarsen et al., 2009), was used to measure bullying behavior in the workplace and consisted of 22 questions. The NAQ-R survey questions were analyzed for the frequency of response to the five categories of bullying (“never,” “now and then,” “monthly,” “weekly,” and “daily”). Written permission was obtained from the authors to use this survey instrument for this research study. Einarsen et al. reported that the reliability of the NAQ-R instrument using Cronbach's alpha for the 22 questions is .90, and validity was reported to be determined using the analysis of variance (ANOVA) using one-way ANOVA. Einarsen et al. note that victims of bullying reported a much higher score on the 22 questions than nonvictims (p b .001). The threshold to measure bullying in this research study was achieved if participants chose a daily or weekly rating on the NAQ-R. Questions of the instrument were arranged into three categories, “person-related bullying,” “work-related bullying,” and “physically intimidating bullying” (Einarsen et al., 2009). Einarsen et al. (2009) developed a latent class cluster approach to compare and analyze participant's responses to the 22 items on the NAQ-R questionnaire. Three of seven of Einarsen et al.'s latent clusters were compared as norms to the new graduate nurses in this research study for the following categories/questions/percentages: workrelated bullying (1, 3, 14, 16, 18, 19, and 21) at 10%, person-related bullying (2, 4, 5, 6, 7, 10, 11, 12, 13, 15, 17, and 20) at 13%, and physically intimidating bullying (8, 9, and 22) at 3%.
Procedure The new nursing graduate participants in this electronic survey study provided their informed consent because they chose to participate and submitted the survey. The participants received the NAQ-R 22-item survey questionnaire, including educational, job and career retention, and demographic questions for completion. The bullying definition was given to the participants after they responded to the 22 items to achieve unbiased survey results (Einarsen et al., 2009).
Data Analysis The 22 questions on the NAQ-R survey were first analyzed for the frequency of new graduates that responded to five categories of bullying (never, now and then, monthly, weekly, and daily). Percentages for each question indicating weekly and daily occurrences revealed that serious bullying was occurring in the workplace. Any frequency of percentages at or more than 10% was considered to be serious. Table 1 summarizes the percentages of respondents that claimed the following behaviors that occurred in the
NEW GRADUATE NURSES' PERCEPTION OF THE WORKPLACE
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Table 1. Comparison of NAQ-R Behaviors of Einarsen and New Graduate Nurses Einarsen and new graduate nurse results compared (daily/weekly) Einarsen
New graduate nurse
Expected, %
Observed, % (n)
χ2
Work-related bullying 1. Withholding information 3. Working below one's competence 14. Having opinions ignored 16. Given tasks with impossible deadline 18. Being excessively monitored 19. Being pressured to not claim entitlements 21. Having unmanageable workload
10 10 10 10 10 10 10
5.9 (8.0) 10.5 (14) 8.2 (11) 8.2 (11) 7.5 (10) 7.4 (10) 17.1 (23)
1.15 0.01 0.02 0.20 0.39 0.43 2.10
Person-related bullying 2. Being humiliated/ridiculed 4. Responsibility removed/trivial tasks 5. Spreading gossip about you 6. Being ignored/secluded 7. Insulting remarks 10. Hints at quitting job 11. Being reminded of mistakes 12. Being ignored or hostility 13. Persistent criticism 15. Practical jokes by adversaries 17. Allegations against you 20. Excessive teasing/sarcasm
13 13 13 13 13 13 13 13 13 13 13 13
2.9 (8) 7.4 (10) 8.1 (11) 11.3 (15) 5.9 (8) 3.7 (5) 2.2 (3) 7.4 (10) 1.4 (2) 2.9 (4) 1.4 (2) 4.4 (6)
6.87 1.71 1.27 0.14 2.95 5.65 5.30 1.71 10.07 6.97 10.07 4.66
3 3 3
5.9 (8) 3.7 (5) 1.4 (2)
NAQ-R/Behaviors (n = 135)
Physically intimidating bullying 8. Being shouted at 9. Intimidating behavior 22. Threats of violence Tool: NAQ-R (Einarsen et al., 2009).
.99 .08 .59
p ns ns ns ns ns ns ns
.0083* ns ns ns ns .0174* .004* ns .0015* .0083* .0015* .031*
ns ns ns
Note. ns = nonsignificant. * = significance.
categories work-related bullying, person-related bullying, and physically intimidating bullying. The respondents in the new nurse graduate survey selected frequencies for daily and weekly, were compared with Einarsen et al. (2009) landmark study, and determined if bullying was significant or not significant using chi-square with one degree of freedom.
Participant Demographics The new graduate nurse respondents (135) were overwhelmingly White, non-Hispanic (92.6%), worked in the hospital setting (83%), and were staff nurses (80.3%). The majority had a bachelor's degree (65.1%), followed by associate degree (20%) and master's degree (13.3%). Other educational backgrounds were 1.5%. See Table 2.
Results NAQ-R/Behavior Survey Table 1 presents work-related bullying and the frequency scores on new nurse graduates compared with Einarsen et al. (2009) population norm for each question. New
nurse graduates reported negative behaviors and “workplace bullying” as significant to all seven questions. Of importance is noting that new graduate nurses reported on weekly and daily events, that 10.5% were ordered to work below their competence, and that 17.1% were exposed to an unmanageable workload. Person-related bullying questions were responded to by the new nurse graduates on a daily and weekly basis except for Question 11 and Question 15. Statistically significant and nonsignificant differences were found of the specific new graduate's responses. The reason for statistically different results of this research compared with Einarsen et al. (2009) population is that less person-related bullying was reported by the new nurse graduates. When analyzing person-related bullying, there was a significant difference for questions (2, 10, 11, 13, 15, 17, and 20). These specific questions were not identified by the new nurse graduates because they were in Einarsen's study. New graduate nurses were much like the population norm for questions (4, 5, 6, 7, and 12). Of importance are that 11.3% of the new graduates
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Table 2. Population Demographics: (n = 135) Variable Race frequency White, non-Hispanic Black or African American Hispanic and other Practice settings Ambulatory care Community/Public health/Home care Hospital Nursing home or extended care Nursing education Unemployed/Other Nursing role Staff nurse Charge nurse Nurse manager Supervisor Instructor/Faculty CNS Nurse practitioner Office nurse Educational background Associate degree Bachelor of science in nursing Bachelor's degree, another area MSN Direct entry, MSN Master's degree, another field Other
Frequency
%
125 7 3
92.6 5.2 2.2
2 2 112 11 2 6
1.5 1.5 83.0 8.1 1.5 4.5
106 10 1 3 2 1 8 1
80.3 7.6 .8 2.3 1.5 .8 6.1 .8
27 82 6 12 5 1 2
20.0 60.7 4.4 8.9 3.7 .7 1.5
CNS = Clinical nurse specialist; MSN = Master of Science in Nursing.
reported that they were ignored or secluded, 8.1% reported that gossip was spread about them, and 7.4% reported that trivial tasks were given to them because their responsibility was removed. For some new graduate nurses, the occurrence of negative behaviors were increased up to three times as often on a monthly basis related to person-related bullying. Monthly meetings may be a situation where bullying is occurring because 21.1% of new graduates reported that they were ignored and secluded, 15.5% reported that there was gossip spread about them, 14% reported that insulting remarks were made about them, and 12.6% reported that their responsibility was removed and that they were given trivial tasks. This report may be a hint for those in management or staff development that some staff or managers bully during the monthly meetings. Physically intimidating bullying, a very serious form of bullying, was reported on a weekly or daily basis by 5.9% of new nurse respondents as being shouted at or being the target of someone's spontaneous anger (or rage). Another 3.7% of the respondents reported intimidating behavior such as finger pointing, invasion of their personal space, shoving, and blocking/barring the way. A threat of violence or physical abuse or actual abuse was reported by 1.4% of new nurse graduates. It is interesting that on a monthly basis, the intimidating behavior was reported to occur 10.4%.
Any physical threats of violence should be taken very seriously by health care organizations. Employees need to have a reporting system in the health organization, and the bully should be subject to disciplinary action. Questions (8, 9, and 22) were all not statistically significant and were similar to Einarsen et al.'s population norm. The results for the physically intimidating bullying and work-related bullying subscales were not statistically different when compared with findings published by Einarsen et al. (2009) indicating that the new graduate nurse encountered similar problems in the workplace. New nurse graduates reported that they “were ignored and secluded” (11.3%), “were forced to work below their competence” (10.5%), “their opinions were ignored” (8.2%), and “they were assigned tasks with impossible deadlines” (8.2%). However, some statistically significant differences were found when comparing the new graduate nurses with Einarsen et al.'s (2009) landmark study. In the personrelated bullying subscale, several statistically significant differences were found in the items measured: “Being humiliated/ridiculed” (p = .0083), “hints at quitting job” (p = .0174), “being reminded of mistakes” (p = .004), “persistent criticism” (p = .0015), “practical jokes by adversaries” (p = .0083), “allegations against you” (p = .0015), and “excessive teasing/sarcasm” (p = .031). These results are all less than Einarsen et al.'s research and may be related to the education of the nurse to the professional nursing role. Cronbach's alpha for the instrument was .828 in this nursing research study indicating good internal consistency.
New Graduate Nurse Relational Questionnaire Table 3, the relational questionnaire, included 20.5% of nurse respondents reporting that they had been bullied in the workplace. New graduate nurses (46.7%) reported that they had seen others as the subject of bullying during the last 6 months. Thirty-one percent of new graduates reported that bullying had affected their job performance. This is a serious issue because patient care and job satisfaction could be affected. Nurses deal with critical life and death issues and cannot be distracted from doing their work by being bullied or working in a bullying environment. New graduate nurses, 29.5%, reported that they had considered leaving nursing because of negative behaviors in the workplace. Of the new graduate nurses that had been bullied, 35.4% had changed jobs within the past 2 years and reported that negative behaviors in the workplace did make a difference and affected their decision to change jobs. New graduate nurses (82.8%) reported that workplace bullying should be included in the nursing curricula, but only 22.4% of the nurse respondents reported that the topic of bullying was covered in nursing coursework. New graduate nurses (59.6%) reported that they had a mentor in the workplace. It is important that 35.1% of the group did not report that management was supportive of bullied
NEW GRADUATE NURSES' PERCEPTION OF THE WORKPLACE
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Table 3. New Graduate Nurse Relational Questionnaire (n = 135)
If bullied, has job performance been affected? Have you been bullied at work? Have you seen others subjected to bullying within the last 6 months? Have you changed jobs within the last 2 years? Did bullying cause you to change jobs? Have negative behaviors at work made you consider leaving nursing? Was workplace bullying included in formal nursing education? Should workplace bullying be included in formal nursing education? Was bullying included in staff education at health care organization? Should there be a policy in the health organization to deal with bullying? Should there be a person to discuss work issues? Do you feel confident to handle a bully in the workplace? Is management at your workplace supportive of victims? Do you feel that the JCAHO is important?
victims. Employees need a supportive management and reporting system. New nurse graduates, 98.5%, in this research study did report overwhelmingly that health care organizations should launch an organizational approach to provide information to employees about bullying and disruptive behaviors as recommended by JCAHO.
Who is the Bully in the Workplace? Table 4 summarizes the descriptive data of who the new nurse graduate acknowledged was the likely or most likely bully in their workplace. The person most likely to cause a bullying problem in the workplace was the nursing peer, the physician, or the patient's family, each at approximately 60%. The patient, nurse supervisor, and manager administrator were rated at approximately 40% as the likely bully.
Discussion The results of this research study parallels the findings of Einarsen et al.'s (2009) study, and the data suggest that bullying is commonly experienced by new graduate nurses. New graduate nurses (20.5%) reported being bullied more often than 5,288 (10.6%) of British employees from various careers reported in Einarsen's landmark study. Focus groups with nurses in the health care organization may help uncover that something else is occurring in the nursing workplace that needs further exploration. About one third of the new graduate nurses in this research study reported that they did not feel satisfied
Yes, % (n)
No, % (n)
31.6 (30) 20.5 (27) 46.7 (63) 35.4 (45) 13.2 (14) 29.5 (36) 22.4 (30) 82.8 (111) 36.3 (49) 95.5 (128) 59.7 (80) 62.7 (84) 64.9 (87) 98.5 (131)
68.4 (65) 79.5 (105) 53.3 (72) 64.6 (82) 86.8 (92) 70.5 (86) 77.6 (104) 17.2 (23) 63.7 (86) 4.5 (6.0) 40.3 (54) 37.3 (50) 35.1 (47) 1.5 (2.0)
with their job performance and that either changed jobs or considered leaving the nursing profession because of bullying. Of the new nurse graduates, 31.6% reported that the bullying had affected their job performance, 35.4% had changed jobs in the past 2 years, and the negative behaviors at work had made 29.5% of the new nurse graduates consider leaving the nursing profession. This is comparable to Simons' (2008) study on newly licensed nurses in Massachusetts where 31% of the respondents in the survey were leaving the health organization because of bullying. In the Health Resources and Services Administration (2010) who released the National Sample Survey of Registered Nurses (2008), 29.8% of nurses reported that they recently left a nursing position or planned to leave in the next 3 years (Health Resources and Services Administration, 2010). New graduate nurses leaving their job as a result of being bullied in the workplace is an unneeded expense to the health care system and to the new graduate that has spent much time and money to pursue a career in nursing. In addition, these may be low percentages because new graduates may be less likely to quit a job after completing the rigorous nursing education because they have worked hard to be licensed and many have loans to repay. The main bullies reported by the new graduate nurses in the workplace were their peers (63.9%), physician's (59.8%), and a patient's family (59.2%). The most damaging bullying psychologically for a new graduate nurse is from a peer in the same profession. It is troubling that the peer nurse was not seen as supportive but as a
Table 4. Who is the Bully in the Workplace? (n = 135)
Peer or fellow nurse Patient Patient family Manager/Administrator Nursing supervisor Physician Other health workers Others
Likely, % (n)
Most likely, % (n)
Total, % (n)
31.1 (39) 30.8 (11) 47.5 (14) 24.4 (14) 27.1 (14) 34.4 (31) 26.1 (4.0) 3.6 (3.0)
32.8 9.2 11.5 11.8 11.9 25.4 3.5 2.7
63.9 (76) 40.0 (48) 59.2 (71) 36.1 (43) 39.0 (46) 59.8 (73) 29.6 (34) 6.3 (7.0)
(37) (37) (57) (29) (32) (42) (30) (4.0)
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bully. It is unclear whether the reported bullying was hazing as a rite of passage into the professional nurse's role. Further studies are needed to discover the reasons for bullying of new graduate nurses by other nurses. The finding that physicians were perceived as sources of bullying by new graduate nurses was not unexpected. Physicians have been noted in the literature of having power struggles with nursing. The dynamic includes a gender issue because, historically, physicians have generally been male and, nurses, female. Nurses also typically take medical orders from physicians, which places nurses in the subservient position of “following orders.” One potential approach to address bullying by physicians is through education. Cultural competency training in medical school needs to include civility, diversity, and sensitivity training for physicians in their relationships with other health professionals. One surprising finding was that the patient's family was one of the main sources of bullying. This is a topic that nursing education and health care organizations should accentuate to help prepare new graduate nurses for negative patient family interactions. Families are under a lot of stress and often take out their frustrations on the nurses. Nurses need knowledge on how to manage conflicts and how to deflect some of this negativity in order to maintain open communication for the patient. Although one perspective may be to blame the family, it appears that some family cultures may be uninformed of the relationship of the nurse as a caregiver for the patient. Another explanation for the families' behavior may be related to the lack of control the family experiences in hospital or health care environments. Similarly, the family may lack sufficient communication with the nurse. This is an important issue because families rely most on nurses for information and communication. The nurse's increased workload may not allow for adequate time to communicate with families about the patient. Qualitative studies on families and nurses are needed to discover whether the family is acting out with the nurse to get information, or if the families who bully live in a culture of bullying, or there are a combination of factors leading to bullying behaviors. Of those reporting, 83% of new graduate nurses worked in a hospital setting, and 80.3% were staff nurses in this research study. “Having an unmanageable workload” (17.1%) was reported at an exceptionally high rate compared with Einarsen et al.'s (2009) study. Health care financial constraints and the nursing shortage both contribute to excessive workloads and lead to an environment for bullying to occur. Practical jokes, teasing, and openly humiliating others were less reported in this research study than in Einarsen et al.'s (2009) study. This behavior is less likely projected in the culture of nursing. Professionalism is taught in nursing school, and student nurses would not display overt behaviors such as playing practical jokes, teasing, and openly humiliating others because they are unprofessional. Persistent criticism may be less of an issue for many new graduates compared with Einarsen et al.
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because they may not recognize criticism as a form of bullying and because some may even view it as constructive. Some new nurse graduates may be desensitized to criticism as a result of their nursing education. New graduates reported “being shouted at” (5.9%) in the workplace and experiencing “intimidating behavior” (3.7%), which is physically intrusive and nonprofessional. Physically intimidating bullying, being shouted at (5.9%), occurred twice as often for new nurse graduates compared with the employees in Einarsen et al.'s (2009) study. These types of nonprofessional behaviors could help explain why new graduate nurses are changing jobs and considering leaving the profession. Future studies are needed to find out why inappropriate behaviors, such as shouting at fellow employees, are tolerated in a health care organization and especially when directed at new graduate nurses. A minority of new nurse graduates (22.4%) reported that bullying information was included in their nursing education, but 82.8% thought it should be included. Of those reporting, only 36.3% reported that bullying was in their staff education when hired to a health care organization. The findings suggest that new nurse graduates and all employees need information on how to handle bullies and stand up for victims. Some workplace issues for the new graduate nurse could be resolved, especially if a senior nurse was available to provide mentorship. In this study, 59.7% of the nurses had a mentor to discuss workplace issues, and 62.7% felt confident to handle a bully. It is interesting that approximately one third of the new nurse graduates had considered leaving the profession and that approximately two thirds of the new graduates had a mentor and felt confident to handle a bully. A supportive mentor who helps the new graduate feel confidence may be a deterrent for the new nurse graduate's decision to change jobs or leave the profession. This is another area for future studies. Employees often do not recognize the patterns of behavior that constitute bullying. Education during orientation and staff development in-services within the health care organization to all employees are crucial.
Conclusion Bullying is a problem in the workplace. Nurses are being bullied from three directions: peers who they are working with, physicians who they take orders from, and patient's families who they are providing care. The findings of this study suggest that further research is needed to learn about the dynamics of bullying. There is also a need for advocacy in nursing that provides clear communication with families, a team approach, and an increased sensitivity to families' needs. Education is important for the new nurse graduate to learn to stand up for their self, and sensitivity training is needed for all members of the health care team. Health care employers have the responsibility to be knowledgeable about the occurrence of hostility in the workplace. Bullying terms should be openly communicated with staff, and education about organizational
NEW GRADUATE NURSES' PERCEPTION OF THE WORKPLACE
policies dealing with negative workplace behaviors is needed. A reporting system for staff to identify hostile, negative behaviors in the workplace is suggested, and an investigation should occur; especially if there is a high rate of staff turnover, absenteeism, and staff complaints (Bartholowmew, 2006). Research on the hostile work environment for nurses in health care recommends that managers in health care organizations need education about bullying so that they feel empowered to manage and educate staff. Bartholowmew states that staff mimics the leadership style of the manager and will also develop a sense of empowerment. Assertiveness training for all staff would improve communication, which is necessary to identify hostile staff behaviors. Bartholowmew encourages nursing leaders to decrease hostility by developing a zero-tolerance policy for hostile behaviors. JCAHO (2008) provides accreditation to hospitals in the United States and also issued a directive beginning in 2009 requiring health care organizations to have a process to deal with bullying and interruptive behavior in the workplace. Individual states in the United States are encouraged to tackle bullying through their state boards of nursing and introduce legislation to address horizontal violence or bullying behaviors. In the state of OH, USA, legislation of zero tolerance for bullying is pending, and education is cited as the key component to protect against workplace violence (Brunt, Hoopingarner, Nanna, Nicholson, Smith, & Valentino, 2007). Some of the strategies include the following: (a) Nurses should be educated in assessing workplace violence; (b) Each employee should have violence prevention information in orientation and mandatory updates; (c) Nurses should be educated about how to identify and manage agitation; and (d) Regular documented training sessions on violence are to take place within organizations. These educational strategies on how to recognize negative acts in the workplace would help staff prevent bullying events by dissuading perpetrators. Health care management has a responsibility to support those who are victims of bullies and provide bullies the education and necessary referrals that are needed. Administrators in health care organizations need to take bullying seriously and establish an environment that is supportive to victims and promotes zero tolerance for bullying. By initiating education to all staff about the overt and covert behaviors that constitute bullying, the bullying experience for many can be prevented. Awareness is needed by nursing leaders of bullying tactics such as shouting or ignoring another staff member. Employees need specific information on bullying language within their organization and steps to eliminate bullying. Beginning steps include a formal departmental policy, a reporting form, counseling sessions for the bully and victim, and consequences for negative behaviors. Nursing cannot afford to lose new graduate nurses or any nurse from the profession in these times of a nursing shortage. Educators and nurse managers especially need to take a stand to interrupt bullying behaviors.
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Respect, civility, assertiveness, and conflict management need to be professional topics introduced in undergraduate education and reinforced in workplaces. Nurse employees need to know the following: Who are the bullies? What overt and covert bullying behaviors do bullies exhibit? How do you handle bullies in the workplace? How can employees prevent bullying? Does the workplace support efforts to report bullying? The ultimate goal is to eliminate the power of the bully in the workplace and create a harmonious work environment. Educational information helps prevent new graduate nurses from leaving the profession.
Limitations This study had a small sample size of newly licensed nurses from five nursing schools in Northwest Ohio in Midwestern United States. One may not be able to generalize the findings to newly graduated nurses in other parts of the United States or internationally. Many participants from the five nursing schools in Northwest Ohio did not check their e-mails on a regular basis after leaving nursing school. For this reason, it is anticipated that many newly graduated RNs did not receive the survey. Another explanation for the low response rate is that the participants who experienced bullying may have been more likely to respond to the survey than those who had not experienced bullying. One wonders about the full extent of the bullying problem because we do not know what the nonresponder group was like.
Recommendations for Future Studies This research study provides the foundation for the need for nursing leaders and educators to provide information to students and staff nurses on bullying in the work environment. Some recommendations for nursing educators are that undergraduate nursing students need to be able to recognize bullying behaviors and how to manage bullying. The nursing curriculum should teach both of these concepts. Nursing students need to be introduced to these concepts when they enter the nursing program, and these concepts need to be reinforced throughout the entire curriculum. Prior to graduation, special emphasis needs to be placed on these concepts to prepare graduating students for entering into nursing practice. The curriculum for nursing students should include in their leadership/management course role-playing scenarios of how to handle a bully (peers, other staff, patient, and family) in the workplace. By practicing how to react to a bully as a student, the new graduate nurse will be better prepared to react confidently and assuredly. It is imperative that new nurse graduates recognize and are prepared to handle bullying in the workplace. Red flags that should alarm a new graduate nurse that he or she is being bullied include having an unmanageable workload, being criticized, humiliated, teased, ignored, isolated, devalued, blamed, sabotaged, or being shouted at. In addition, new graduate nurses should be encouraged to ask for a supportive mentor when newly hired within a health care organization. As a new graduate nurse, if a bullying
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situation occurs, the new graduate needs to request the bully to stop their behavior. If the bullying does not stop, the new graduate nurse needs to keep a written record and report any bullying incidences to their supervisor. A sound health care organization should have antibullying policies, which includes the statement that the organization has zero tolerance for bullying. Future studies may analyze workplace bullying after new nursing graduates or new employees have been provided information in staff education and orientation about the signs of a bullying work environment. Future studies should also be done on the seasoned nurse's perception of bullying in the workplace. Studies on new nurse graduates could include their knowledge of conflict management techniques and strategies to diffuse bullying. Physicians also need bullying information in their medical training and in staff development sessions within health care organizations. Bullying is a serious problem and may have serious consequences for the victim, patients, and the organization. Nurses must promote the ANA Code of Ethics (2003) where patients and staff are treated with respect and dignity. A civil workplace should be the right of all employees.
References Adams, A. (1997). Bullying at work—How to confront and overcome it. London: Virago Press. American Nurses Association. (2003). Nursing scope and standards of practice. Washington, D.C.: The Association. http://nursingworld.org/MainMenuCategories/ThePracticeof ProfessionalNursing/Ethicsstandards/CodeofEthics.aspx. Andersson, L. M., & Pearson, C. M. (1999). Tit for tat? The spiraling effect of incivility in the workplace. Academy of Management Review, 24, 452–471. Backstrum, C. H., & Hursh-Cesar, G. (1981). Survey research. New York: MacMillan Publishing. Bowles, C., & Candela, L. (2005). First job experiences of recent R.N. graduates improving the work environment. Journal of Nursing Administration, 35, 130–137. Bartholowmew, K. (2006). Ending nurse to nurse hostility: Why nurses eat their young and each other. Marblehead, MA: HCPro, Inc. Brunt, B. A., Hoopingarner, S., Nanna, K., Nicholson, K., Smith, Y., & Valentino, M. (2007). Position statement on workplace violence: Nursing practice statement NP 83. Columbus, OH: Ohio Nurses Association. Dellesega, C. (2009). Bullying among nurses: Relational aggression is one form of bullying. What can nurses do about it? American Journal of Nursing, 109, 52–58. Einarsen, S. (1999). The nature and causes of bullying at work. International Journal of Manpower, 20, 16–27. Einarsen, S., & Hoel, H. (2001). The Negative Acts Questionnaire development, validation, and revision of a measure of bullying at work. Paper presented at 10th Annual European Congress in Work and Organizational Psychology, 2001; Prague, Czechoslovakia Republic. 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, 24–44. Einarsen, S., Hoel, H., Zapf, D., Cooper, C. L. (Eds.). Bullying and emotional abuse in the workplace. International perspectives in research and practice. London: Taylor & Francis. Einarsen, S., Raknes, B. I., & Matthieson, S. B. (1994). Bullying and its relationship to work and environment quality: An exploratory study. European Work and Organizational Psychologist, 4, 381–401. Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of Continuing Nursing Education in Nursing, 35, 257–263. Health Resources and Services Administration. (2010). The registered nurse population: Initial findings from the 2008 National Sample Survey of Registered Nurses. Washington, DC: U.S. Department of Health and Human Resources. Hubert, A., Furda, J., & Steensma, H. (2001). Mobbing, Systematisch pesgedrag in organisaties: Twee studies naar antecedenten en gevolgen voor de gezondheid (Mobbing, systemic bullying behavior within organizations: Two studies for antecedents and health consequences). Gedrag en Organisatie, 14, 378–396. Johnson, S., & Rea, R. E. (2009). Workplace bullying: Concerns for nurse leaders. The Journal of Nursing Administration, 39, 84–90. Leymann, H. (1996). The content and development of mobbing at work. European Journal of Work and Occupational Psychology, 5, 165–184. Longo, J., & Sherman, R. O. (2007). Leveling horizontal violence. Nursing Management www.nursingmanagement.com. Lutgen-Sandvik, P., Tracy, S., & Alberts, J. (2007). Burned by bullying in the American workplace: Prevalence, perception, degree, and impact. Journal of Management Studies, 44, 837–862. PricewaterhouseCoopers' (PCW) Health research Institute (HRI). (2007). What works* Healing the healthcare shortage. www.pwc.com/healthindustries; www.pwc.com/hri. Rayner, C. H., & Keashly, L. (2005). Bullying at work: A perspective from Britain and North America. In S. Fox, P. Spector (Eds.). Counterproductive Work Behavior. (pp. 271–296). Washington, DC: American Psychological Association. Silence Kills: The seven crucial conversations for healthcare. http://www.silencekills.com. Simons, S. (2008). Workplace bullying experienced by Massachusetts registered nurses and the relationship to intention to leave the organization. Advances in Nursing Science, 31, E48–E49. The Joint Commission. (2008). Behaviors that undermine a culture of safety. Sentinel Event Alert, 40, 1–3. The Joint Commission news release. Joint Commission alert: Stop bad behavior among health professionals. http://www. jointcommission.org/NewsRoom/News Releases/nr_07_ 09_08.htm. Title VII Civil Rights Act of 1964, Pub. L. 88–352, 78 stat 241, July 2, 1964. U.S. Department of Health & Human Services. (2007, November). Monthly Labor Review, www.bis.gov/opub/mir/ 2007/11/art5full.pdf. Workplace Bullying Institute. (2010). workplacebullying.org. Zapf, D., & Gross, C. (2001). Conflict escalation and coping with workplace bullying: A replication and extension. European Journal of Work Organizational Psychology, 10, 497–522.
R
EGISTERED NURSES (RNS) ARE increasingly in high demand in health care organizations to care for acutely ill patients, yet a significant numbers of RNs leave the profession within a few years of graduating. Research indicates that 30%–60% of new graduate nurses actually leave or intend to leave their nursing jobs after 6 months to 1 year (Bowles & Candela, 2005; Bartholowmew, 2006; Simons, 2008). Among various reasons for this, it is suspected that a hostile work environment, more specifically bullying in the workplace, may contribute to RNs leaving their jobs and profession (Johnson & Rea, 2009; Simons, 2008; Bartholowmew, 2006, Bowles & Candela, 2005). Recommendations from professional organizations (American Nurses Association [ANA], 2003; The Joint Commission [JCAHO], 2008) call for participation of ⁎Assistant Professor, The University of Toledo, Toledo, OH. †Professor, The University of Toledo, Toledo, OH. Address correspondence to Dr. Vogelpohl: The University of Toledo, College of Nursing, Health Science Campus, Mail Stop 1026, 3000 Arlington Ave., 3213 Collier Building, Toledo, OH 43614. E-mail: [email protected] 8755-7223/12/$ - see front matter 414 http://dx.doi.org/10.1016/j.profnurs.2012.10.008
leaders/managers in skill-based training to focus on unprofessional employee behavior and conflict resolution. Workplace bullying has been described as a persistent, enduring form of abuse that involves negative actions and interactions at work (Lutgen-Sandvik, Tracy, & Alberts, 2007). There are catastrophic results for both the organization and the target of bullying of this current and prevalent workplace dilemma (Einarsen, Hoel, Zapf, & Cooper, 2003; Rayner & Keashly, 2005). Statistics project the crisis in health care that is occurring as the result of the nursing shortage and replacement costs for the health care organization and consumers. The U.S. Bureau of Labor Statistics (2007) has projected that more than 1 million replacement nurses will be needed to accommodate health care needs in the United States by 2016 (U.S. Department of Health and Services, 2007). A hospital with a poor nursing retention rate could spend annually an average of $3.6 million more than a hospital with a good nursing retention rate (PricewaterhouseCoopers' Health research Institute, 2007). The victims of workplace bullying can be very costly to health care organizations (the Workplace Bullying Institute, 2010). Lawsuits are pursued by some employees to seek justice against the aggressor or
Journal of Professional Nursing, Vol 29, No. 6 (November/December), 2013: pp 414–422 © 2013 Elsevier Inc. All rights reserved.
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organization, and the litigation and settlements cost up to $1.4 million. They project that a Fortune 500 Company could spend up to $24,000,000 annually between staff turnover and lost productivity. In addition, as a result of abusive behavior among staff, patients were also found to be at a 20% more risk of harm from professionals in the Silence Kills (2005) study. Bullying in the workplace is costly financially for the health organization and is a destructive force in human relationships. Longo and Sherman (2007) summed the personal effects of horizontal violence. Nurse victims experience powerlessness and eventually experience the following health problems as a result of horizontal violence: (a) insomnia, (b) low self-esteem, (c) low work morale, (d) disconnection from others, (e) depression, and (f) usage of more sick leave than the nurse not involved in horizontal violence. The overall purpose of this study was to investigate the bullying experience of the newly graduated RN. Workrelated bullying, person-related bullying, and physically intimidating bullying are the three factors identified as negative work experiences (Einarsen, Hoel, & Notelaers, 2009) using the (Negative Acts Questionnaire–Revised [NAQ-R]) survey tool. The purposes of this study were to find if the newly graduated RN experienced these types of bullying, determine the relational affects bullying has on the newly graduated RN, and determine who does the bullying.
Literature Review In the 1960s, workplace harassment in the United States revolved mainly around sexual and racial harassment cases. The Title VII Civil Rights Act of 1964 provided legal grounds to stop harassment issues and prevent discriminatory practices of employers to their employees. Workplace bullying is a recently identified form of harassment that is being studied more intensely in the United States during the past decade. During the last two decades, most of the workplace research has been done in European countries, the United Kingdom, and Australia (Dellesega, 2009). In the United States, there is one major U.S. workplace study on various professions (Lutgen-Sandvik et al., 2007) and a few U.S. studies in the nursing profession (Johnson & Rea, 2009; Simons, 2008; Bowles & Candela, 2005; Bartholowmew, 2006; Griffin, 2004). The newly licensed nurse chose to leave the nursing profession because of problems in the work environment in one U.S. study. The survey involved 352 RNs who graduated from a basic nursing program in NV, USA (Bowles & Candela, 2005). As a result of a negative work environment, these authors reported that 30% of new nurses left their job within the first year, and 57% left by the second year. In Bartholowmew's (2006) study, 60% of RNs in the United States were found to leave their first position within 6 months because of horizontal violence. Ninety to 97% of nurses reported verbal abuse from physicians.
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Simons (2008) did the first U.S. study on nurses in the workplace using the NAQ-R (Einarsen & Hoel, 2001). The study determined that workplace bullying was experienced by newly licensed RNs within 6 months of employment after becoming an RN. Simons' study determined if RNs intended to leave the organization as a result of being bullied. Thirty-one percent of the participants in Simons' study did relate their experience of being bullied in the workplace, which was interpreted as a major determinant of their intent to leave the organization. Using the operational definition of the NAQ-R survey, bullying consisted of at least two bullying behaviors on a weekly or daily basis occurring during the past 6 months. Bullying was found to be higher in this study than those in other international studies previously done using the NAQ-R and using this operational definition of bullying. The seriousness of disruptive nursing behavior is summarized by JCAHO (2008) that released Sentinel Alert 40, requiring health care facilities to ensure that health care organizations design an organizational approach to make employees aware of bullying and disruptive behaviors (The Joint Commission news release). Harmful behaviors between staff that are rude and hostile are threatening to the provision of quality patient care and prompted JCAHO to address them in accreditations of health organizations. Statistics of the JCAHO (2008) survey found that 50% of nurses had been a victim of bullying and/or disruptive behavior in the workplace, and 90% stated that they witnessed others being the brunt of abuse within their organization. Einarsen (1999) is one of the major researchers in the area of workplace bullying. His group, the Bergen Bullying Research Group at the University of Norway, has been studying bullying for years and developed survey instruments to collect data. Einarsen and Hoel (2001) explain that workplace bullying is a situation where a person feels mistreated because they are persistently exposed to interpersonal aggression over a long period. Dealing with interpersonal aggression can have a devastating effect on the person and organization in which they work.
Concepts and Definitions Bullying is the persistent act of demeaning and downgrading another person through cruel words and negative actions that undermine another's self-confidence and self-esteem (Adams, 1997). Bullying, a growing problem in society, involves maltreatment of one person, the victim, by another person(s), and the bully (Einarsen & Hoel, 2001) and includes the aggressors' tactics of offending behaviors, harassment, and/or social exclusion. In addition, bullying is described as repeated incidents (e.g., once/week) and for a certain amount of time (e.g., 6 months). A single occurrence with two opposing persons having a single conflict does not constitute bullying (Zapf & Gross, 2001). The bullying conflict is difficult to resolve because there is often a power disparity between the
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bully and victim. The bullying on the surface appears nonaggressive, which makes it difficult for a victim to speak out about the aggression (Lutgen-Sandvik et al., 2007; Leymann, 1996, Zapf & Gross, 2001). Workplace bullying is distinct from other definitions such as incivility or disruptive behaviors because the behaviors of the bully toward the victim are not random acts, are intentional, and occur over an extended period. Workplace incivility is defined as disrespectful deviant work behaviors of a person to harm another that violates workplace rules (Andersson & Pearson, 1999. In addition, uncivil behaviors are generally discourteous and rude and demonstrate the lack of mutual respect in the workplace. Most of the cases of workplace bullying are negative psychological acts. Issues may involve work issues (e.g., withholding information needed in a job) or nonwork issues (e.g., humiliating and insulting acts), and the victim has difficulty defending himself or herself (Einarsen, Raknes, & Matthieson, 1994; Leymann, 1996). The perpetrator has no intention to stop the bullying tactics directed toward the victim in workplace bullying (Hubert, Furda, & Steensma, 2001). The intent of this research study using the NAQ-R and relational questionnaire was to determine if new graduate nurses recognized bullying tactics, were bullied as a newly licensed RN, intended to leave nursing, identified the bullies in the workplace, and received education/ support from employers.
Method This descriptive research study surveyed a convenience sample of newly licensed RNs' perception of bullying occurrence in the workplace. The main characteristics included the sampling of the newly licensed RN population, and information was collected through an electronic survey. Bullying behaviors in the workplace were identified utilizing the survey tool, the NAQ-R, the “New Graduate Nurses Relational Questionnaire,” and questions identifying the bully in the workplace.
Sample Population A survey design was implemented to determine the perceptions of the new graduate nurse RN regarding bullying in the workplace. This research study was submitted to the institutional review board for review. The questionnaire was sent electronically to the target population, 2,079 newly licensed alumni nurses from 2007 to 2010. Five Northwest Ohio Colleges of Nursing Alumni Associations were included in the electronic email survey. Three mailings at 1–2 weeks after the initial e-mail were sent to get the maximum return rate. The single random sample size was set with a confidence level of 95% (α = .5) and the total tolerated reduction error of no more than plus or minus 5% (Backstrum & HurshCesar, 1981). Of the 2,079 participants who were sent the survey, 135 (7%) of newly licensed nurses responded. Participants were informed that privacy and confidentiality were incorporated within the data collection
process, and only one person at the institutional research center had access. The survey data submitted were gathered using Vovici software.
Survey Instrument The survey instrument, the NAQ-R (Einarsen et al., 2009), was used to measure bullying behavior in the workplace and consisted of 22 questions. The NAQ-R survey questions were analyzed for the frequency of response to the five categories of bullying (“never,” “now and then,” “monthly,” “weekly,” and “daily”). Written permission was obtained from the authors to use this survey instrument for this research study. Einarsen et al. reported that the reliability of the NAQ-R instrument using Cronbach's alpha for the 22 questions is .90, and validity was reported to be determined using the analysis of variance (ANOVA) using one-way ANOVA. Einarsen et al. note that victims of bullying reported a much higher score on the 22 questions than nonvictims (p b .001). The threshold to measure bullying in this research study was achieved if participants chose a daily or weekly rating on the NAQ-R. Questions of the instrument were arranged into three categories, “person-related bullying,” “work-related bullying,” and “physically intimidating bullying” (Einarsen et al., 2009). Einarsen et al. (2009) developed a latent class cluster approach to compare and analyze participant's responses to the 22 items on the NAQ-R questionnaire. Three of seven of Einarsen et al.'s latent clusters were compared as norms to the new graduate nurses in this research study for the following categories/questions/percentages: workrelated bullying (1, 3, 14, 16, 18, 19, and 21) at 10%, person-related bullying (2, 4, 5, 6, 7, 10, 11, 12, 13, 15, 17, and 20) at 13%, and physically intimidating bullying (8, 9, and 22) at 3%.
Procedure The new nursing graduate participants in this electronic survey study provided their informed consent because they chose to participate and submitted the survey. The participants received the NAQ-R 22-item survey questionnaire, including educational, job and career retention, and demographic questions for completion. The bullying definition was given to the participants after they responded to the 22 items to achieve unbiased survey results (Einarsen et al., 2009).
Data Analysis The 22 questions on the NAQ-R survey were first analyzed for the frequency of new graduates that responded to five categories of bullying (never, now and then, monthly, weekly, and daily). Percentages for each question indicating weekly and daily occurrences revealed that serious bullying was occurring in the workplace. Any frequency of percentages at or more than 10% was considered to be serious. Table 1 summarizes the percentages of respondents that claimed the following behaviors that occurred in the
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Table 1. Comparison of NAQ-R Behaviors of Einarsen and New Graduate Nurses Einarsen and new graduate nurse results compared (daily/weekly) Einarsen
New graduate nurse
Expected, %
Observed, % (n)
χ2
Work-related bullying 1. Withholding information 3. Working below one's competence 14. Having opinions ignored 16. Given tasks with impossible deadline 18. Being excessively monitored 19. Being pressured to not claim entitlements 21. Having unmanageable workload
10 10 10 10 10 10 10
5.9 (8.0) 10.5 (14) 8.2 (11) 8.2 (11) 7.5 (10) 7.4 (10) 17.1 (23)
1.15 0.01 0.02 0.20 0.39 0.43 2.10
Person-related bullying 2. Being humiliated/ridiculed 4. Responsibility removed/trivial tasks 5. Spreading gossip about you 6. Being ignored/secluded 7. Insulting remarks 10. Hints at quitting job 11. Being reminded of mistakes 12. Being ignored or hostility 13. Persistent criticism 15. Practical jokes by adversaries 17. Allegations against you 20. Excessive teasing/sarcasm
13 13 13 13 13 13 13 13 13 13 13 13
2.9 (8) 7.4 (10) 8.1 (11) 11.3 (15) 5.9 (8) 3.7 (5) 2.2 (3) 7.4 (10) 1.4 (2) 2.9 (4) 1.4 (2) 4.4 (6)
6.87 1.71 1.27 0.14 2.95 5.65 5.30 1.71 10.07 6.97 10.07 4.66
3 3 3
5.9 (8) 3.7 (5) 1.4 (2)
NAQ-R/Behaviors (n = 135)
Physically intimidating bullying 8. Being shouted at 9. Intimidating behavior 22. Threats of violence Tool: NAQ-R (Einarsen et al., 2009).
.99 .08 .59
p ns ns ns ns ns ns ns
.0083* ns ns ns ns .0174* .004* ns .0015* .0083* .0015* .031*
ns ns ns
Note. ns = nonsignificant. * = significance.
categories work-related bullying, person-related bullying, and physically intimidating bullying. The respondents in the new nurse graduate survey selected frequencies for daily and weekly, were compared with Einarsen et al. (2009) landmark study, and determined if bullying was significant or not significant using chi-square with one degree of freedom.
Participant Demographics The new graduate nurse respondents (135) were overwhelmingly White, non-Hispanic (92.6%), worked in the hospital setting (83%), and were staff nurses (80.3%). The majority had a bachelor's degree (65.1%), followed by associate degree (20%) and master's degree (13.3%). Other educational backgrounds were 1.5%. See Table 2.
Results NAQ-R/Behavior Survey Table 1 presents work-related bullying and the frequency scores on new nurse graduates compared with Einarsen et al. (2009) population norm for each question. New
nurse graduates reported negative behaviors and “workplace bullying” as significant to all seven questions. Of importance is noting that new graduate nurses reported on weekly and daily events, that 10.5% were ordered to work below their competence, and that 17.1% were exposed to an unmanageable workload. Person-related bullying questions were responded to by the new nurse graduates on a daily and weekly basis except for Question 11 and Question 15. Statistically significant and nonsignificant differences were found of the specific new graduate's responses. The reason for statistically different results of this research compared with Einarsen et al. (2009) population is that less person-related bullying was reported by the new nurse graduates. When analyzing person-related bullying, there was a significant difference for questions (2, 10, 11, 13, 15, 17, and 20). These specific questions were not identified by the new nurse graduates because they were in Einarsen's study. New graduate nurses were much like the population norm for questions (4, 5, 6, 7, and 12). Of importance are that 11.3% of the new graduates
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Table 2. Population Demographics: (n = 135) Variable Race frequency White, non-Hispanic Black or African American Hispanic and other Practice settings Ambulatory care Community/Public health/Home care Hospital Nursing home or extended care Nursing education Unemployed/Other Nursing role Staff nurse Charge nurse Nurse manager Supervisor Instructor/Faculty CNS Nurse practitioner Office nurse Educational background Associate degree Bachelor of science in nursing Bachelor's degree, another area MSN Direct entry, MSN Master's degree, another field Other
Frequency
%
125 7 3
92.6 5.2 2.2
2 2 112 11 2 6
1.5 1.5 83.0 8.1 1.5 4.5
106 10 1 3 2 1 8 1
80.3 7.6 .8 2.3 1.5 .8 6.1 .8
27 82 6 12 5 1 2
20.0 60.7 4.4 8.9 3.7 .7 1.5
CNS = Clinical nurse specialist; MSN = Master of Science in Nursing.
reported that they were ignored or secluded, 8.1% reported that gossip was spread about them, and 7.4% reported that trivial tasks were given to them because their responsibility was removed. For some new graduate nurses, the occurrence of negative behaviors were increased up to three times as often on a monthly basis related to person-related bullying. Monthly meetings may be a situation where bullying is occurring because 21.1% of new graduates reported that they were ignored and secluded, 15.5% reported that there was gossip spread about them, 14% reported that insulting remarks were made about them, and 12.6% reported that their responsibility was removed and that they were given trivial tasks. This report may be a hint for those in management or staff development that some staff or managers bully during the monthly meetings. Physically intimidating bullying, a very serious form of bullying, was reported on a weekly or daily basis by 5.9% of new nurse respondents as being shouted at or being the target of someone's spontaneous anger (or rage). Another 3.7% of the respondents reported intimidating behavior such as finger pointing, invasion of their personal space, shoving, and blocking/barring the way. A threat of violence or physical abuse or actual abuse was reported by 1.4% of new nurse graduates. It is interesting that on a monthly basis, the intimidating behavior was reported to occur 10.4%.
Any physical threats of violence should be taken very seriously by health care organizations. Employees need to have a reporting system in the health organization, and the bully should be subject to disciplinary action. Questions (8, 9, and 22) were all not statistically significant and were similar to Einarsen et al.'s population norm. The results for the physically intimidating bullying and work-related bullying subscales were not statistically different when compared with findings published by Einarsen et al. (2009) indicating that the new graduate nurse encountered similar problems in the workplace. New nurse graduates reported that they “were ignored and secluded” (11.3%), “were forced to work below their competence” (10.5%), “their opinions were ignored” (8.2%), and “they were assigned tasks with impossible deadlines” (8.2%). However, some statistically significant differences were found when comparing the new graduate nurses with Einarsen et al.'s (2009) landmark study. In the personrelated bullying subscale, several statistically significant differences were found in the items measured: “Being humiliated/ridiculed” (p = .0083), “hints at quitting job” (p = .0174), “being reminded of mistakes” (p = .004), “persistent criticism” (p = .0015), “practical jokes by adversaries” (p = .0083), “allegations against you” (p = .0015), and “excessive teasing/sarcasm” (p = .031). These results are all less than Einarsen et al.'s research and may be related to the education of the nurse to the professional nursing role. Cronbach's alpha for the instrument was .828 in this nursing research study indicating good internal consistency.
New Graduate Nurse Relational Questionnaire Table 3, the relational questionnaire, included 20.5% of nurse respondents reporting that they had been bullied in the workplace. New graduate nurses (46.7%) reported that they had seen others as the subject of bullying during the last 6 months. Thirty-one percent of new graduates reported that bullying had affected their job performance. This is a serious issue because patient care and job satisfaction could be affected. Nurses deal with critical life and death issues and cannot be distracted from doing their work by being bullied or working in a bullying environment. New graduate nurses, 29.5%, reported that they had considered leaving nursing because of negative behaviors in the workplace. Of the new graduate nurses that had been bullied, 35.4% had changed jobs within the past 2 years and reported that negative behaviors in the workplace did make a difference and affected their decision to change jobs. New graduate nurses (82.8%) reported that workplace bullying should be included in the nursing curricula, but only 22.4% of the nurse respondents reported that the topic of bullying was covered in nursing coursework. New graduate nurses (59.6%) reported that they had a mentor in the workplace. It is important that 35.1% of the group did not report that management was supportive of bullied
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Table 3. New Graduate Nurse Relational Questionnaire (n = 135)
If bullied, has job performance been affected? Have you been bullied at work? Have you seen others subjected to bullying within the last 6 months? Have you changed jobs within the last 2 years? Did bullying cause you to change jobs? Have negative behaviors at work made you consider leaving nursing? Was workplace bullying included in formal nursing education? Should workplace bullying be included in formal nursing education? Was bullying included in staff education at health care organization? Should there be a policy in the health organization to deal with bullying? Should there be a person to discuss work issues? Do you feel confident to handle a bully in the workplace? Is management at your workplace supportive of victims? Do you feel that the JCAHO is important?
victims. Employees need a supportive management and reporting system. New nurse graduates, 98.5%, in this research study did report overwhelmingly that health care organizations should launch an organizational approach to provide information to employees about bullying and disruptive behaviors as recommended by JCAHO.
Who is the Bully in the Workplace? Table 4 summarizes the descriptive data of who the new nurse graduate acknowledged was the likely or most likely bully in their workplace. The person most likely to cause a bullying problem in the workplace was the nursing peer, the physician, or the patient's family, each at approximately 60%. The patient, nurse supervisor, and manager administrator were rated at approximately 40% as the likely bully.
Discussion The results of this research study parallels the findings of Einarsen et al.'s (2009) study, and the data suggest that bullying is commonly experienced by new graduate nurses. New graduate nurses (20.5%) reported being bullied more often than 5,288 (10.6%) of British employees from various careers reported in Einarsen's landmark study. Focus groups with nurses in the health care organization may help uncover that something else is occurring in the nursing workplace that needs further exploration. About one third of the new graduate nurses in this research study reported that they did not feel satisfied
Yes, % (n)
No, % (n)
31.6 (30) 20.5 (27) 46.7 (63) 35.4 (45) 13.2 (14) 29.5 (36) 22.4 (30) 82.8 (111) 36.3 (49) 95.5 (128) 59.7 (80) 62.7 (84) 64.9 (87) 98.5 (131)
68.4 (65) 79.5 (105) 53.3 (72) 64.6 (82) 86.8 (92) 70.5 (86) 77.6 (104) 17.2 (23) 63.7 (86) 4.5 (6.0) 40.3 (54) 37.3 (50) 35.1 (47) 1.5 (2.0)
with their job performance and that either changed jobs or considered leaving the nursing profession because of bullying. Of the new nurse graduates, 31.6% reported that the bullying had affected their job performance, 35.4% had changed jobs in the past 2 years, and the negative behaviors at work had made 29.5% of the new nurse graduates consider leaving the nursing profession. This is comparable to Simons' (2008) study on newly licensed nurses in Massachusetts where 31% of the respondents in the survey were leaving the health organization because of bullying. In the Health Resources and Services Administration (2010) who released the National Sample Survey of Registered Nurses (2008), 29.8% of nurses reported that they recently left a nursing position or planned to leave in the next 3 years (Health Resources and Services Administration, 2010). New graduate nurses leaving their job as a result of being bullied in the workplace is an unneeded expense to the health care system and to the new graduate that has spent much time and money to pursue a career in nursing. In addition, these may be low percentages because new graduates may be less likely to quit a job after completing the rigorous nursing education because they have worked hard to be licensed and many have loans to repay. The main bullies reported by the new graduate nurses in the workplace were their peers (63.9%), physician's (59.8%), and a patient's family (59.2%). The most damaging bullying psychologically for a new graduate nurse is from a peer in the same profession. It is troubling that the peer nurse was not seen as supportive but as a
Table 4. Who is the Bully in the Workplace? (n = 135)
Peer or fellow nurse Patient Patient family Manager/Administrator Nursing supervisor Physician Other health workers Others
Likely, % (n)
Most likely, % (n)
Total, % (n)
31.1 (39) 30.8 (11) 47.5 (14) 24.4 (14) 27.1 (14) 34.4 (31) 26.1 (4.0) 3.6 (3.0)
32.8 9.2 11.5 11.8 11.9 25.4 3.5 2.7
63.9 (76) 40.0 (48) 59.2 (71) 36.1 (43) 39.0 (46) 59.8 (73) 29.6 (34) 6.3 (7.0)
(37) (37) (57) (29) (32) (42) (30) (4.0)
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bully. It is unclear whether the reported bullying was hazing as a rite of passage into the professional nurse's role. Further studies are needed to discover the reasons for bullying of new graduate nurses by other nurses. The finding that physicians were perceived as sources of bullying by new graduate nurses was not unexpected. Physicians have been noted in the literature of having power struggles with nursing. The dynamic includes a gender issue because, historically, physicians have generally been male and, nurses, female. Nurses also typically take medical orders from physicians, which places nurses in the subservient position of “following orders.” One potential approach to address bullying by physicians is through education. Cultural competency training in medical school needs to include civility, diversity, and sensitivity training for physicians in their relationships with other health professionals. One surprising finding was that the patient's family was one of the main sources of bullying. This is a topic that nursing education and health care organizations should accentuate to help prepare new graduate nurses for negative patient family interactions. Families are under a lot of stress and often take out their frustrations on the nurses. Nurses need knowledge on how to manage conflicts and how to deflect some of this negativity in order to maintain open communication for the patient. Although one perspective may be to blame the family, it appears that some family cultures may be uninformed of the relationship of the nurse as a caregiver for the patient. Another explanation for the families' behavior may be related to the lack of control the family experiences in hospital or health care environments. Similarly, the family may lack sufficient communication with the nurse. This is an important issue because families rely most on nurses for information and communication. The nurse's increased workload may not allow for adequate time to communicate with families about the patient. Qualitative studies on families and nurses are needed to discover whether the family is acting out with the nurse to get information, or if the families who bully live in a culture of bullying, or there are a combination of factors leading to bullying behaviors. Of those reporting, 83% of new graduate nurses worked in a hospital setting, and 80.3% were staff nurses in this research study. “Having an unmanageable workload” (17.1%) was reported at an exceptionally high rate compared with Einarsen et al.'s (2009) study. Health care financial constraints and the nursing shortage both contribute to excessive workloads and lead to an environment for bullying to occur. Practical jokes, teasing, and openly humiliating others were less reported in this research study than in Einarsen et al.'s (2009) study. This behavior is less likely projected in the culture of nursing. Professionalism is taught in nursing school, and student nurses would not display overt behaviors such as playing practical jokes, teasing, and openly humiliating others because they are unprofessional. Persistent criticism may be less of an issue for many new graduates compared with Einarsen et al.
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because they may not recognize criticism as a form of bullying and because some may even view it as constructive. Some new nurse graduates may be desensitized to criticism as a result of their nursing education. New graduates reported “being shouted at” (5.9%) in the workplace and experiencing “intimidating behavior” (3.7%), which is physically intrusive and nonprofessional. Physically intimidating bullying, being shouted at (5.9%), occurred twice as often for new nurse graduates compared with the employees in Einarsen et al.'s (2009) study. These types of nonprofessional behaviors could help explain why new graduate nurses are changing jobs and considering leaving the profession. Future studies are needed to find out why inappropriate behaviors, such as shouting at fellow employees, are tolerated in a health care organization and especially when directed at new graduate nurses. A minority of new nurse graduates (22.4%) reported that bullying information was included in their nursing education, but 82.8% thought it should be included. Of those reporting, only 36.3% reported that bullying was in their staff education when hired to a health care organization. The findings suggest that new nurse graduates and all employees need information on how to handle bullies and stand up for victims. Some workplace issues for the new graduate nurse could be resolved, especially if a senior nurse was available to provide mentorship. In this study, 59.7% of the nurses had a mentor to discuss workplace issues, and 62.7% felt confident to handle a bully. It is interesting that approximately one third of the new nurse graduates had considered leaving the profession and that approximately two thirds of the new graduates had a mentor and felt confident to handle a bully. A supportive mentor who helps the new graduate feel confidence may be a deterrent for the new nurse graduate's decision to change jobs or leave the profession. This is another area for future studies. Employees often do not recognize the patterns of behavior that constitute bullying. Education during orientation and staff development in-services within the health care organization to all employees are crucial.
Conclusion Bullying is a problem in the workplace. Nurses are being bullied from three directions: peers who they are working with, physicians who they take orders from, and patient's families who they are providing care. The findings of this study suggest that further research is needed to learn about the dynamics of bullying. There is also a need for advocacy in nursing that provides clear communication with families, a team approach, and an increased sensitivity to families' needs. Education is important for the new nurse graduate to learn to stand up for their self, and sensitivity training is needed for all members of the health care team. Health care employers have the responsibility to be knowledgeable about the occurrence of hostility in the workplace. Bullying terms should be openly communicated with staff, and education about organizational
NEW GRADUATE NURSES' PERCEPTION OF THE WORKPLACE
policies dealing with negative workplace behaviors is needed. A reporting system for staff to identify hostile, negative behaviors in the workplace is suggested, and an investigation should occur; especially if there is a high rate of staff turnover, absenteeism, and staff complaints (Bartholowmew, 2006). Research on the hostile work environment for nurses in health care recommends that managers in health care organizations need education about bullying so that they feel empowered to manage and educate staff. Bartholowmew states that staff mimics the leadership style of the manager and will also develop a sense of empowerment. Assertiveness training for all staff would improve communication, which is necessary to identify hostile staff behaviors. Bartholowmew encourages nursing leaders to decrease hostility by developing a zero-tolerance policy for hostile behaviors. JCAHO (2008) provides accreditation to hospitals in the United States and also issued a directive beginning in 2009 requiring health care organizations to have a process to deal with bullying and interruptive behavior in the workplace. Individual states in the United States are encouraged to tackle bullying through their state boards of nursing and introduce legislation to address horizontal violence or bullying behaviors. In the state of OH, USA, legislation of zero tolerance for bullying is pending, and education is cited as the key component to protect against workplace violence (Brunt, Hoopingarner, Nanna, Nicholson, Smith, & Valentino, 2007). Some of the strategies include the following: (a) Nurses should be educated in assessing workplace violence; (b) Each employee should have violence prevention information in orientation and mandatory updates; (c) Nurses should be educated about how to identify and manage agitation; and (d) Regular documented training sessions on violence are to take place within organizations. These educational strategies on how to recognize negative acts in the workplace would help staff prevent bullying events by dissuading perpetrators. Health care management has a responsibility to support those who are victims of bullies and provide bullies the education and necessary referrals that are needed. Administrators in health care organizations need to take bullying seriously and establish an environment that is supportive to victims and promotes zero tolerance for bullying. By initiating education to all staff about the overt and covert behaviors that constitute bullying, the bullying experience for many can be prevented. Awareness is needed by nursing leaders of bullying tactics such as shouting or ignoring another staff member. Employees need specific information on bullying language within their organization and steps to eliminate bullying. Beginning steps include a formal departmental policy, a reporting form, counseling sessions for the bully and victim, and consequences for negative behaviors. Nursing cannot afford to lose new graduate nurses or any nurse from the profession in these times of a nursing shortage. Educators and nurse managers especially need to take a stand to interrupt bullying behaviors.
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Respect, civility, assertiveness, and conflict management need to be professional topics introduced in undergraduate education and reinforced in workplaces. Nurse employees need to know the following: Who are the bullies? What overt and covert bullying behaviors do bullies exhibit? How do you handle bullies in the workplace? How can employees prevent bullying? Does the workplace support efforts to report bullying? The ultimate goal is to eliminate the power of the bully in the workplace and create a harmonious work environment. Educational information helps prevent new graduate nurses from leaving the profession.
Limitations This study had a small sample size of newly licensed nurses from five nursing schools in Northwest Ohio in Midwestern United States. One may not be able to generalize the findings to newly graduated nurses in other parts of the United States or internationally. Many participants from the five nursing schools in Northwest Ohio did not check their e-mails on a regular basis after leaving nursing school. For this reason, it is anticipated that many newly graduated RNs did not receive the survey. Another explanation for the low response rate is that the participants who experienced bullying may have been more likely to respond to the survey than those who had not experienced bullying. One wonders about the full extent of the bullying problem because we do not know what the nonresponder group was like.
Recommendations for Future Studies This research study provides the foundation for the need for nursing leaders and educators to provide information to students and staff nurses on bullying in the work environment. Some recommendations for nursing educators are that undergraduate nursing students need to be able to recognize bullying behaviors and how to manage bullying. The nursing curriculum should teach both of these concepts. Nursing students need to be introduced to these concepts when they enter the nursing program, and these concepts need to be reinforced throughout the entire curriculum. Prior to graduation, special emphasis needs to be placed on these concepts to prepare graduating students for entering into nursing practice. The curriculum for nursing students should include in their leadership/management course role-playing scenarios of how to handle a bully (peers, other staff, patient, and family) in the workplace. By practicing how to react to a bully as a student, the new graduate nurse will be better prepared to react confidently and assuredly. It is imperative that new nurse graduates recognize and are prepared to handle bullying in the workplace. Red flags that should alarm a new graduate nurse that he or she is being bullied include having an unmanageable workload, being criticized, humiliated, teased, ignored, isolated, devalued, blamed, sabotaged, or being shouted at. In addition, new graduate nurses should be encouraged to ask for a supportive mentor when newly hired within a health care organization. As a new graduate nurse, if a bullying
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situation occurs, the new graduate needs to request the bully to stop their behavior. If the bullying does not stop, the new graduate nurse needs to keep a written record and report any bullying incidences to their supervisor. A sound health care organization should have antibullying policies, which includes the statement that the organization has zero tolerance for bullying. Future studies may analyze workplace bullying after new nursing graduates or new employees have been provided information in staff education and orientation about the signs of a bullying work environment. Future studies should also be done on the seasoned nurse's perception of bullying in the workplace. Studies on new nurse graduates could include their knowledge of conflict management techniques and strategies to diffuse bullying. Physicians also need bullying information in their medical training and in staff development sessions within health care organizations. Bullying is a serious problem and may have serious consequences for the victim, patients, and the organization. Nurses must promote the ANA Code of Ethics (2003) where patients and staff are treated with respect and dignity. A civil workplace should be the right of all employees.
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