May 25th, 2010
Guest blog: Bullying and Nurses
Destructive Workplace Behaviors and Turnover in Nursing by Cheryl Painter, MBA/HCM/NHCE, BSHA, PhD candidate, published in the Arizona Healthcare Executives, Spring 2009.
Destructive workplace behaviors contribute to the inability to retain nurses in the healthcare environment because of the stress associated with these behaviors. Briles (2003) defined the problem of destructive workplace behavior as “working manners, habits, and styles that can directly and negatively affect the bottom line of a unit, department, and the entire organization” (Red Ink Behavior section 2).
These destructive workplace behaviors cause targeted employees to experience serious physical and psychological damage (Rowe & Sherlock, 2005), resulting in negative aspects of the EVLN model, which consists of exit – leaving employment, voice – verbal threats of retaliation, loyalty – entrapment by the organization, and neglect – willful negligence to work duties. The resulting organizational decline costs the healthcare organization both time in retraining new employees and money to mitigate the effects of EVLN.
Considering the nursing shortage and the increasing demand for healthcare services, strategies need implemented to improve satisfaction, increase motivation, augment productivity, and improve retention to ensure safe and quality healthcare. The cause and mitigation of these destructive behaviors are illustrated by presenting a background of various aspects of cultural liability in the current nurse environment and are validated by examining three studies that address lateral/horizontal hostility as well as the supervisor or management’s roles in recognizing and addressing abuse.
Destructive workplace behaviors consist of demeaning, abusive, and hostile communications or actions among employees. Lateral hostility or disruptive behavior among or between coworkers is prominent within the nursing profession. A survey conducted by Alspach (2007) revealed that “25% to 32% of … critical care RNs reported only fair or poor quality of interactions with peers…, especially in relation to respect and verbal abuse” (p. 10). Nurses described various forms of verbal abuse or bullying as blatant or subtle communication that caused emotional distress using words or tone as well as intimidating, threatening, or patronizing mannerisms.
Some examples of individual workplace bullying include, but are not limited to sabotaging, engaging in the silent treatment, spreading rumors, devaluing a peer, discounting input, or fault-finding. The resulting behaviors are manifested in the EVLN model. Individual workplace bullying, “manifested by one RN toward another, represents system and cultural issues, symptoms of an emotionally, spiritually, and psychologically toxic and oppressive environment” (Alspach, 2007, p. 11). Individual or lateral destructive workplace behavior has deep seated origins. Frustrations with working conditions may cause some nurses to redirect hostile behaviors toward other nurses. Another viewpoint proclaimed bullying type behavior emerges from power struggles, leadership styles, and organizational conditions. Furthermore, some believe lateral destructive workplace behaviors are learned from the existing organizational culture.
Horizontal hostility involves conflict or destructive workplace behavior by group members toward other individuals outside the group or toward group members themselves as a means of conformity. Another definition of horizontal violence is groupthink. Capella University (2005) defined groupthink as a “phenomenon in which the norm for consensus overrides the realistic appraisal of alternative courses of action” (p.217). Groupthink or mobbing emulates the concepts of horizontal violence in which an oppressive leader, who has attained a degree of status, causes oppressed group behavior. The oppressor attains the ability to control others to achieve self-serving goals in a way that humiliates or denigrates the self-esteem of those on his or her hit list and creates a toxic work environment.
Culture as a Liability
The toxic workplace environment created by dysfunctional aspects of internal and external influences creates “a culture as a liability” (Capella University, 2005, p. 491). Cultural liability is amplified when nurses experience burnout because of heavy workloads and lack of recognition. The most pressing trends that contribute to destructive workplace behaviors and foster toxic healthcare work environments include an increasing nurse workload because of an aging and growing population, increasing age of the registered nurse workforce and nurse faculty, increasing turnover of nurses, decreasing enrollment in nursing schools, and cost-cutting pressures of managed care (Jorgensen-Huston, 2003). The increased job stress associated with heavy workloads is amplified and turnover is increased when nurse managers, physicians, patient family members, patients, or coworkers fail to recognize nurses for good performance and impose abusive interactions.
The lack of recognition coupled with decreased job satisfaction intensifies destructive workplace behaviors, increases turnover, affects patient outcomes, and amplifies costs to the organization.
The cost to replace a staff nurse was 1.2 to 1.3 times that of a nurse’s average annual salary. High vacancy and turnover rates can adversely affect patient outcomes due to the loss of experienced staff and increased stress on the remaining nurses whose already heavy workload increases to overcome the effect of vacancies. (Texas Center for Nurse Workforce Studies, 2006, p.2)
Therefore, the goal for healthcare leaders is to mitigate the effects of destructive workplace behaviors causing the toxic work environment by creating a healthy work environment that supports the nurse.
Culture as an Asset
In a healthy workplace environment, nurses thrive because of increased morale, increased job satisfaction, and decreased turnover. “The environment in which RNs work is an essential issue in their job satisfaction and turnover…. and a healthy work environment is the base for recruiting and retaining nurses and ultimately for providing optimal care for patients…” (Ulrich, Lavandero, Hart, Woods, Leggett, & Taylor, 2006, p. 46). Hospitals that have achieved Magnet Status – best practices in nursing – have high satisfaction, low turnover, and optimized nurse-to-patient ratios.
Factors that contribute to Magnet Status include nurse autonomy and control over his or her working environment and effective/respectful communication among nurses, physicians, team members, and management.
The American College of Critical Care Nurses (AACN) recognized the issue of hostile or destructive workplace behaviors, mandated a zero tolerance for abuse policy, and identified some components in a healthy workplace environment to include collaborative communication; mutual respect; competent nursing leadership; protection from physical, verbal, and emotional abuse; influence and control over practice; professional development; and recognition.
Despite the AACN policy for zero tolerance for abuse, an open – online survey reported over “9000 instances” (Ulrich et al., 2006, p.54) of verbal, emotional, and physical abuse. Nurse leaders must strive to create healthy work environments; however, as evidence from the survey results more research is needed to address destructive workplace behaviors of nurses, groups of nurses, coworkers, leadership or physicians, and clients. The following studies will explore the phenomena of destructive nurse workplace behaviors and will identify potential causes and solutions to the problem.
Nurses cite physician abuse as one of the major reasons they resign. “…disruptive physician behavior refers to any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse, to physical and sexual harassment….; two-thirds of nurses say they [have] been abused by physicians at least once every two to three months…” (Rosenstein, 2002, p.27). To determine the relationship between nurse turnover and abusive physician relationships as well as divergent views amongst nurses, physicians, and administration, Rosenstein (2002) administered the Nurse-Physician Relationship Survey.
The most striking finding in the survey indicated that 92.5% or 1,089 respondents have seen physicians abusing nurses (Rosenstein, 2002). The most frequent forms of abuse witnessed include physicians yelling at and berating nurses. Nurses feared retribution and believed they received minimal administrative support when physician abuse occurred. Abusive physician behavior toward nurses does increase turnover; the survey indicated that 30.7% of the respondents have either quit or witnessed another nurse quitting because of hostile physician behaviors.
Although respondents did not concur on the best approach, the most cited solutions were collaboration and communication, education and training, open forums and group discussions, and greater accountability for both nurses and physicians (Rosenstein, 2002). Accountability could be enforced by using a professional’s code of ethics, reporting abusive behaviors to the ethics committees, and establishing a zero tolerance for abuse policies as recommended by the AACN.
Rowe and Sherlock’s Study
Rowe and Sherlock’s (2005) study explored the frequencies, types, and effects of verbal abuse experienced between nurses. Based on previous studies, nurses are an oppressed group that displays characteristics of occupational burnout that turns the oppressed into the oppressor. Bullying is both psychological and physically damaging and has a direct influence on job satisfaction, morale, and retention. Victims report feelings to include, but not limited to isolation, lower self-esteem, rejection, powerlessness, uselessness, depression, and hopelessness (Rowe & Sherlock, 2005). Frequent verbal abuse with the accompanying psychological and physiological manifestations causes nurses to accept or perpetuate the destructive behavior or resign.
The results of the survey indicated that verbal abuse does occur both laterally and horizontally between nurses, but also from other sources such as physicians, patients, patient family members, and ancillary staff. The most prominent source for verbal abuse is lateral hostility between nurses (Rowe & Sherlock, 2005). The most frequent types of abuse were hostile, judgmental, and critical communications. Nurses reported both constructive and unconstructive coping behaviors ranging from clarification by dealing directly with the abusive nurse to using silence, calling in sick, complaining about the work environment, or resigning.
The recommendation to mitigate verbal abuse and its effects centers on practice management. Using creative morale building strategies is a start to change destructive workplace behaviors. One way to improve morale is to get nurses involved in decisions involving policies and procedures (Rowe & Sherlock, 2005). Empowerment is a strong motivating factor. When nurses are involved, organizational commitment and positive organizational behaviors increase. In addition to empowerment, a nurse’s morale is increased by enforcing a zero abuse policy, encouraging nurses to report abuse, and educating staff on destructive workplace behaviors.
Yildirim, Yildirim, and Timucin’s Study
Yildirim’s et al (2007) study explored mobbing or groupthink type behavior among nurse faculty in Turkey. The psychological terror of mobbing begins when a group of individuals single out one or more victims and attack their “honor, honesty, reliability, and professional ability…” (p. 447). The various attitudes and behaviors of the oppressors create a type of “psychological violence” (p. 447) that frightens, excludes, isolates, and delays a victim from accessing organizational resources that enforce his or her rights. Mobbing is becoming more prevalent among nurses in a variety of healthcare and education environments and has devastating physical and psychological effects on victims. Various responses to mobbing include, but are not limited to fatigue, stress, headaches, post-traumatic stress disorder (PTSD), suicide, unexplained fears, insomnia, loss of appetite, heart palpitations, depression, weight gain or loss, neglect of work duties, absenteeism, and turnover.
Yildirim’s et al. (2007) study revealed that 91% of nursing staff who took part in the study had experienced mob type behavior and 26.6% of nursing staff experienced mobbing behavior two times a week on the average. “The most frequent forms of [mobbing] behaviors included attacks on personal status (85%) and attacks on personality (82%)…” (p. 451). In addition to the aforementioned responses to mobbing listed in the description of the authors’ study, victims of mobbing experienced mistrust of coworkers, continuance organizational commitment, and retaliation toward other nurses. The coping mechanism most used in a mobbing situation was the victim working harder and becoming better organized to avoid criticism. Other nurses assumed a proactive approach by confronting the abusers directly and trying to work out a resolution. Fifty percent of those that experienced mobbing reported that they resigned their position.
Healthcare leaders, nurse managers, nurse educators, and nursing staff need to become more aware of mobbing behavior through formal educational forums. The extreme negative implications of destructive workplace behavior such as mobbing create long-lasting psychological consequences for the victim. Yildirim et al (2007) suggested that mobbing behavior be prosecuted as a felony. Policies and procedures, such as the zero tolerance for abuse policy recommended by the AACN, should be enforced and abusive behaviors should be reported. To avoid fear or apprehension in reporting abuse, the authors suggested forming a committee of nurses who have witnessed or experienced mobbing behavior.
In conclusion, destructive workplace behavior among nurses is a very real and serious phenomenon that affects the health of the victims, the bottom line of the healthcare organization, and the quality of outcomes for patients. By examining the nurses’ culture as a liability, one can appreciate how both internal and external factors contribute to these dysfunctional behaviors. In a healthy workplace environment, nurses thrive because of increased morale, increased job satisfaction, and decreased turnover. What are the differences in these two environments? The answer is empowerment, recognition, trust, autonomy, communication, professional development, respect, and accountability. The three studies emulated the components of both a healthy and toxic workplace and revealed issues that involved lateral, horizontal, and institutional response to abusive behavior. A common theme in the three studies and the nurses’ current work environment is the importance of job satisfaction in the retention of nurses.
Alspach, G. (2007). Critical care nurses: Are our intentions nice or nasty? Critical Care Nurse, 27(3), 10-14.
Briles, J. (2003). Zapping conflict in the healthcare workplace. Denver, CO: Mile High Press, Ltd.
Capella University (2005). OM: 8004: Managing and organizing people (An Edited Work). Boston, Prentice Hill Custom Publishing.
Jorgensen Huston, C. (2003). Quality health care in an era of limited resources: Challenges and opportunities. Journal of Nursing Care Quality, 18(4), 1-12.
Rosenstein, A. (2002). Nurse–physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 102(6), 26-34.
Rowe, M. & Sherlock, H. (2005). Stress and verbal abuse in nursing: Do burned- out nurses eat their young? Journal of Nursing Management, 13, 242-248.
Texas Center for Nursing Workforce Studies. (2006, September). The economic impact of the nursing shortage. E-Publication # 25-12515.
Ulrich, B., Lavandero, R., Hart, K., Woods, D., Leggett, J. & Taylor, D. (2006). Critical care nurses’ work environments: A baseline status report. Critical Care Nurse, 26(5), 46-56.
Yildirim, D., Yildirim, A., & Timucin, A. (2007). Mobbing behaviors encountered by nurse teaching staff. Nursing Ethics, 14(4), 447-461.
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