Bullying in Nursing: Implementing Solutions

for PracticeMatthew S. Howard, DNP, RN, CEN, CPEN, CPN

Director of Educational Resources – SigmaStaff Nurse II – Eskenazi Health

Jennifer L. Embree, DNP, RN, NE-BC, CCNSClinical Associate Professor – Indiana University School of Nursing

Magnet Coordinator – Eskenazi Health

Background

2

￮ Incivility and bullying is increasing

￮ Interpersonal hostility, bullying, toxic work environments are documented in nursing

(Al- Hamdan , Manojlovich , & Tanima , 2017; Attell , Brown, & Treiber , 2017; Butler, Prentiss, & Benaamor , 2018; Chang, Carter, Ng, Flynn, & Tan, 2017; Edmonson, Bolick, & Lee, 2017; Hoguh et al., 2016; Manton, 2017; Meires , 2018; Salin & Notelaers , 2017)

(Adriaenssens , De Gucht, & Maes , 2015; Christie & Jones, 2014; Dellasega, Volpe, Edmonson, & Hopkins, 2014; Elmblad , Kodjebacheva , & Lebeck , 2014; Flinkman & Salanterä , 2015; Park, Cho, & Hong, 2015)

Background￮ Define the problem￮ Multiple names – multiple meanings

3

Background￮ Frequently examined within the literature ￮ Recognized epidemic￮ Still continues

4(Castronovo , Pullizzi, & Evans, 2016; Coile , 2016; Edmonson et al., 2017; Fleming, 2016; Giorgi et al., 2016; Granstra , 2015; Manton, 2017; Wilson, 2016; Wolf, Perhats , Clark, Moon, & Zavotsky , 2017)

Background￮ Turnover as a result of bullying

￮ Incivility and bullying becoming more rampant

5

(Bruyneel , Thoelen , Adriaenssens , & Sermeus , 2017; Blackstock, Harlos , Macleod, & Hardy, 2015; Fitzpatrick, Campo, & Lavandero , 2011; Flinkman & Salanterä , 2015; Flinkman , Isopahkala -Bouret , & Salanterä , 2013; Oyeleye , Hanson, O'Connor, & Dunn, 2013; Tarcan , Hikmet , Schooley, Top, & Yorgancıoglu Tarcan , 2017).

Background￮ Incivility, interpersonal hostility, lateral and

horizontal violence, and toxic work

environments are issues many nurses deal

with daily

6

(Adriaenssens et al., 2015; Christie & Jones, 2014; Dellasega et al., 2014; Elmblad et al., 2014; Park et al., 2015)

Background ￮ Negative outcomes as a result of

bullying behaviors have been identified to increase:

○ In te n t to le a ve th e p ro fe ss io n

○ De p a rtm e n t tu rn o ve r

○ He a lth is sue s

○ Me n ta l h e a lth is sue s (d e p re ss io n )

7(Al- Ha m d a n e t a l., 2017; Arn o ld & Wa lsh , 2015)

Ne w Yo rk Po s t

Evidence￮ Descriptive study:

￮ Survey using six validated tools￮ RNs in southeastern US ￮ N = 345 ￮ Findings:

￮ 40% victims of bullying behavior within the previous six months

￮ 68% witnessed co - workers being bullied

8(Sauer & McCoy, 2018)

• Negative Acts Questionnaire• Perceived Stress Scale • Resilience Scale

Evidence￮ Descriptive study:

￮ Survey using four tools￮ RNs at western Canadian hospital ￮ N = 103￮ Findings:

￮ Found positive association between bullying acts and intent to leave the organization

9(Blackstock et al., 2015)

Evidence￮ Descriptive cross - sectional design study:

￮ Survey using two tools￮ RNs in tertiary hospitals in South

Korea ￮ N = 508￮ Findings:

￮ Direct relationship between

jo b sa tis fa c tio n (d ue to b u llyin g

b e h a vio rs ) a n d in te n t to le a ve10

• Ne g a tive Ac ts Que s tio n n a ire• La te ra l Vio le n c e sc a le

(Oh , Uh m , & Yo o n , 2016)

“

Evidence

(Porath & Pearson, 2010, p.64 - 65)

48% intentionally

their work effort.38%

intentionally the quality of

their work. 80% lost work time

worrying about the incident.63%

lost work time avoiding the

offender.

66% said that their performance

declined.

78% said that their

commitment to the organization declined.

12% said that they

left their job because of the uncivil treatment.

11

Am o n g wo rke rs wh o h a ve b e e n o n th e re c e ivin g e n d o f in c ivility:

EvidenceAmong workers who have been on the receiving end of incivility:

(Porath & Pearson, 2010, p.64 - 65)12

94% of targets, get even with bullies

88% of targets, get even with their organization

Lewis and Malecha

o Workplace bullying and incivility cost facilities on average of $11,581 per nurse, per year If only 10% of nurses at the

facility experienced incivility or bullying in the workplace, the cost would be > $1.3M per year in lost productivity.(Lewis & Malecha, 2011)

Background￮ Communicating is often uneasy

￮ A positive work culture relies on effective

and civil communication

14(Blosky & Spegman , 2015; Brockman- Weber, 2016; Drahnak, Hravnak , Ren, Haines, & Tuite, 2016; Hartung & Miller, 2013; Liaw, Zhou, Lau, Siau, & Chan, 2014)

Gaps￮ Descriptive studies

￮ Solutions needed

15

Purpose￮ Examine if an educational activity can:

1. Increase civility

2. Increase comfort level in holding

conversations

16

Conceptual Framework

17(Ren & Kim, 2017, p. 702)

Bullying Experience

Psyc h o lo g ic a l Em p o we rm e n t

Co n flic t Ma n a g e m e n t

Style s

Psychological

Well-being

Depression

Self-esteem

Clinical Satisfaction

Model

18The Johns Hopkins Nursing Evidence - Based Practice Model ( Dearholt & Allan, 2018, p. 36)

Logic Model

Visual tool to represent the relationships between resources and ultimate impact of the project19

Project Design

20

￮ A quasi - experimental mixed methods design study

EG 2InterventionEG 1

CG 2CG 1

Non-random assignment to groups

Control Group

Experimental Group

EG 1, CG 1 = Pre-intervention data collection pointEG 2, CG 2 = Post-intervention data collection point

Pre-intervention Post-intervention

Project Design

21

￮ Inclusion criteria

Control Group

Experimental Group Eskenazi Health RN’s

Currently in standard nursing orientation (between April 2018 and June 2018)

Eskenazi Health RN’s Completed standard nursing orientation

within the last calendar year(between April 2017 and March 2018)

Sent to all nurses who meet inclusion criteria:

Burn Critical Care (ICU)

Emergency DepartmentAcuity Adaptable

ClinicsOB

Operating SuitePsychiatry

Interventional Suites

Non-random assignment to groups

Over 250 met inclusion criteria (N = 266)

Project Design

22

￮ Data collection information

EG 2InterventionEG 1

CG 2CG 1

Non-random assignment to groups

Control Group

Experimental Group

EG 1, CG 1 = Demographics, Workplace Civility Index, Negative Acts Questionnaire- RevisedEG 2, CG 2 = Workplace Civility IndexEG 2 = Intervention specific questions

Pre-intervention Post-intervention

Validated Data Collection Tools Utilized

23

Negative Acts Questionnaire - Revised• A validated 22 - item instrument that

was developed at a university in Bergen, Norway. This instrument measures perceived exposure to bullying and harassment while at work. The tool can identify targets of bullying who will have a larger score compared to non - targets.

Workplace Civility Index • A validated evidence - based

questionnaire constructed to assess a nurses’ personal civility and increase personal awareness related to personal actions and intentions .

(Clark, 2017; Clark, Sattler, & Barbosa - Leiker, 2018) (Einarsen , Hoel , & Notelaers , 2009)

Project Design

24

￮ The intervention

EG 2InterventionEG 1

Non-random assignment to groups

Experimental Group

Pre-intervention Post-intervention

Developed by Sigma Theta Tau International Honor Society of Nursing (Sigma)

Bullying in the Workplace: Solutions for Nursing Practice

Time: ~2 hours 40 minutes

Evidence based solutions

Authors from around the world

Innovative branching scenarios

Branching Scenarios￮ Case studies

25

“

26

27

Branching Scenario Development Slides

5-6

Slides 15-16

Slides 10-11

Slides 20-21

Slide 73

Slide74Go to

Slide 20

Slides 25-26

Go to Slide 61

Go to Slide 20

Slides 40-41

Slides 55-56

Slide63

Slide 64

Slide76-77

Slides 30-31

Slides 45-46

Slide 68

Go to Slide 20

Slides 35-36

Slide 71

Slide 72

Slide 66

Slide 67

Slide 65

Go to Slide 40

Slide69

Slide70

Slide75

Slide 60

Slide 61

Slide 62

Slides 50-51

Best Ending

Go here only if all

great options picked

Most helpful choicesModerately helpful choicesLeast helpful choices

28

AuthorsLaura Dzurec, PhD, RN, PMHCNS-BC, ANEF, FAAN

Cheryl Dellasega, PhD, MSN, CRNPPenn State College of MedicineProfessor

Matthew S. Howard, MSN, RN, CEN, CPEN, CPNSigma; Eskenazi Health Director, Educational Resources; Staff Nurse II

Patricia Gillen, PhD, RN, RM, FHEAUlster UniversityLecturer/ Head of Research and Development

Jennifer L. Embree, DNP, RN, NE-BC, CCNSIndiana University; Eskenazi Health Clinical Associate Professor; Magnet Coordinator

Joanne Navarroli, MSN, RN, CENChandler Regional Medical Center – Dignity HealthStaff/Trauma Nurse

Cheri Clancy, MSN, RN, NEA-BC, CPXPCheri Clancy & Associates, LLCAuthor and speaker

EditorsCynthia Clark, PhD, RN, ANEF, FAAN

ATI Nursing Education+Nurse Consultant

Monica Kennison, EdD, MSN, RNBerea CollegeSusan V Clayton Nursing Chair and Professor

Boston College Senior Scholar and Professor

Project Design

29

￮ Measure of success

EG 2InterventionEG 1

Non-random assignment to groups

Experimental Group

Pre-intervention Post-intervention

More than 80% of participants will have increased their WCI score.

More than 80% of participants will have implemented at least one positive conflict management

strategy effectively.

SMART goals to measure success

Data Analysis ￮ Survey’s via Qualtrics ￮ Data analysis via Microsoft Excel

30

Study Participants:

• Control Group 28

• Experimental Group 21

• Total 49

Invited 266

Responded 70

Completed 49

Rate 18%

Data Analysis ￮ Educational Background

31

Associate Degree

Baccalaureate Degree

Master’s Degree

Doctoral Degree

Control Experimental Total

25.0% 23.8% 24.5%

60.7% 61.9% 61.2%

14.3% 9.5% 12.2%

0.0% 4.8% 2.0%

Data Analysis ￮ Demographics

32

Data Analysis ￮ Demographics

33

As Nurse In HC

Total Total0- 1 years 41% 8%2- 3 years 27% 22%4- 5 years 6% 24%6- 7 years 10% 10%8- 9 years 2% 6%10- 15 years 2% 12%16- 20 years 6% 6%21- 25 years 2% 6%26- 30 years 4% 2%31- 35 years 0% 2%

Validated Data Collection Tools Utilized

34

Workplace Civility Index • A validated evidence - based

questionnaire constructed to assess a nurses’ personal civility and increase personal awareness related to personal actions and intentions .

Scoring the Civility IndexVery civil 90- 100Civil 80- 89Moderately civil 70- 79Minimally civil 60- 69Uncivil 50- 59Very uncivil <50

(Clark, 2017; Clark, Sattler, & Barbosa - Leiker, 2018)

Data Analysis

35

Control GroupWCI Pre

Test TotalWCI Post Test Total

Mean 88.21 80.21Variance 44.62 103.06Observations 28 28Pearson Correlation 0.26df 27t Stat 3.99P(T<=t) one- tail 0.00022t Critical one - tail 1.703P(T<=t) two- tail 0.000454t Critical two - tail 2.052

Experimental GroupWCI Pre

Test TotalWCI Post Test Total

Mean 91.57 95.43Variance 26.76 5.86Observations 21 21Pearson Correlation 0.97df 20t Stat - 6.16P(T<=t) one- tail 2.54t Critical one - tail 1.725P(T<=t) two- tail 5.09t Critical two - tail 2.056

Workplace Civility Index • Pa ire d two sa m p le t- te s t • Th e se c h a n g e s we re s ig n ific a n tly

s ig n ific a n t

(t = - 6 .16 , p = < 00001) (t = 3.99 a n d p = .000227)

Data Analysis ￮ Mean WCI scores

by age ranges by grouping

36

- 8.0- 21.0- 5.8- 9.4- 5.0

2.0 – 4.3

Workplace Civility Index

Results ￮ Differences in the pre -

and post - intervention

37Box and Whisker Chart

Workplace Civility Index

Validated Data Collection Tools Utilized

38

Negative Acts Questionnaire -Revised• A validated 22 - item instrument that

was developed at a university in Bergen, Norway. This instrument measures perceived exposure to bullying and harassment while at work. The tool can identify targets of bullying who will have a larger score compared to non - targets.

Scoring the NAQ - RNot bullied ≤ 32

Oc c a s io n a lly b u llie d

33 – 45

Bu llie d ≥ 46

Sc o re s ra n g e fro m22 - 110

(Einarsen et al., 2009; Notelaers & Einarsen, 2013 )

Results

Overall Mean = 33.59

39

Scoring the NAQ - RNot bullied ≤ 32

Oc c a s io n a lly b u llie d

33 – 45

Bu llie d ≥ 46

Sc o re s ra n g e fro m22 - 110

Co n tro l Gro up M = 32.54 , SD = 8 .88

Exp e rim e n ta l Gro up M = 35 .00 , SD = 21.16

Negative Acts Questionnaire - Revised

Results Mean NAQ - R scores by group

40

0

10

20

30

40

50

60

70

80

Not Bullied Occassionally Bullied Bullied

Control Group Experimental Group

Perc

enta

ge

Negative Acts Questionnaire - Revised

Th e p ro p o rtio n in th e th re e c a te g o rie s a re n o t s ig n ific a n tly d iffe re n t b e twe e n th e two g ro up s .

Results ￮ The P- Value is 0.714623. The result is not significant

at p < 0.05.￮ The proportion in the three categories are not

significantly different between the two groups.

41

Chi - square statistic χ2 0.672048611D.f. 2p- value 0.714605737

Negative Acts Questionnaire - Revised

Results

42

Negative Acts Questionnaire - RevisedHave you been bullied at work over the

last six months?

Control Group• No 75.0%• Yes, but only rarely 14.3%• Yes, now and then 7.1%• Yes, several times per week 3.6%• Yes, almost daily 0.0%Experimental Group• No 81.0%• Yes, but only rarely 4.8%• Yes, now and then 0.0%• Yes, several times per week 9.5%• Yes, almost daily 4.8%

Results – connection to framework and purpose

43(Ren & Kim, 2017, p. 702)

Bullying Experience

Psychological Empowerment

Conflict Management

Styles

Psychological Well-being

Depression

Self-esteem

Clinical Satisfaction

Recommendations ￮ Review measures of success:

44

Mo re th a n 80% o f p a rtic ip a n ts will h a ve in c re a se d

th e ir WCI sc o re .

100% e xp e rim e n ta l g ro up in c re a se d WCI sc o re s (p re - in te rve n tio n M= 91.6 , p o s t- in te rve n tio n M= 95)

(t = - 6 .16 , p = < 00001)

Recommendations ￮ Review measures of success:

45

Mo re th a n 80% o f p a rtic ip a n ts will h a ve

im p le m e n te d a t le a s t o n e p o s itive c o n flic t

m a n a g e m e n t s tra te g y e ffe c tive ly.

An o th e r p a rtic ip a n t s ta te d , “I to o k th e o p p o rtun ity to h a ve a c o n ve rsa tio n with a te c h th a t h a s b e e n ve ry d ism iss ive . Th e c o n ve rsa tio n we n t we ll, b u t tim e will te ll”.

On e p a rtic ip a n t n o te d , “I fe lt c o m fo rta b le h a vin g a c o n ve rsa tio n th a t n e e d e d to h a p p e n a lo n g tim e a g o ”.

An o th e r p a rtic ip a n t n o te d , “th e c o u rse d id g ive m e th e to o ls to sp e a k with a p h ys ic ia n in a p o s itive wa y”.

Conclusions ￮ The implementation of Sigma’s “ Bullying in the

Workplace: Solutions for Nursing Practice ” p ro vid e d

e a rly e vid e n c e to sup p o rt th a t a n a syn c h ro n o us

p ro vid e r- d ire c te d , le a rn e r- p a c e d e - Le a rn in g

e d uc a tio n a l a c tivity can effectively d e c re a se

in c ivility a n d in c re a se p e rc e ive d c o m fo rt with

h o ld in g c ritic a l c o n ve rsa tio n s b e twe e n n u rse s .46

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