y Objectives - NJHAworkplace: A preliminary study for developing personal and organizational strategies for transformation of hostile workplace environments. Journal of Professional

Budin, W. 2017 ©

Addressing Workplace Incivility:

Personal and Professional

Consequences

Wendy C. Budin PhD, RN-BC, FAAN

Professor & Associate Dean

Entry to Baccalaureate Practice

Rutgers School of Nursing

15th Annual ONL NJ Research Day

Nurse Leaders Shape Healthy Practice Environments

Across Multi-Generations

June 9, 2017

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Greetings From…

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• Define workplace bullying and other disruptive behaviors

• Differentiate between bullying and other disruptive behavior

• Discuss…

o factors that may contribute…

o characteristics …

o consequences …

o potential prevention strategies

Objectives

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Budin, W. 2017 ©

• Repetitive offensive, abusive, intimidating, or insulting behaviors,

or unfair sanctions from a person of higher position or power with

the deliberate intent to cause psychological or physical harm.

Recipients feel humiliated, vulnerable, or threatened, thus creating

stress, and undermining their self-confidence. (Vessey et al., 2011)

What is bullying?

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• Repetitive offensive, abusive, intimidating, or insulting behaviors,

or unfair sanctions from a person of higher position or power with

the deliberate intent to cause psychological or physical harm.

Recipients feel humiliated, vulnerable, or threatened, thus creating

stress, and undermining their self-confidence. (Vessey et al., 2011)

What is bullying?

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Various Terms used to describe bullying…

• Bullying

• Horizontal violence

• Lateral violence

• Mobbing

• Harassment

• Disruptive behaviors

• Incivility

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Budin, W. 2017 ©

Bullying vs. Other Disruptive Behaviors?

• Related to horizontal / lateral violence and harassment

• Differs by:

• Power differential (real or perceived)

• Harassment

• Notion of difference

• E.g., age, race, gender, sexual orientation

– Protection against harassment

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Incivility vs. Bullying

How is incivility different than bullying?

• While the behaviors can be similar, they tend to be lower level.

• This is your typical rude, inconsiderate, or just nasty nurse.

• However, make no mistake about it, incivility is a healthy and

professional workplace killer!

Incivility Bullying

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Bullying, Horizontal Violence, Incivility, etc.?

• Terms tend to be used interchangeably

• None are acceptable, but bullying is more damaging

because it is initiated by a “person in power”

• All need to be addressed too but bullying should be a

NEVER event.

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Budin, W. 2017 ©

Elements of Bullying

It is important to note that bullying must have 3 elements :

• The effect is on the recipient - not the intention of the bully

• There must be a negative effect on the victim

• The bullying behavior must be persistent or repeated

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American Nurses Association

• The ANA upholds that all nursing personnel have the right to work

in a healthy work environments free of abusive behaviors such as

bullying, hostility, lateral abuse and violence, sexual harassment,

intimidation, abuse of authority and position reprisal for speaking

out against abuses.

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• Disruptive behavior defined as conduct by staff working in the

organization that intimidates others to the extent that quality and

safety could be compromised. These behaviors, as determined by

the organization, may be verbal or non-verbal, may involve the use

of rude language, may be threatening, or may involve physical

contact. (Leadership chapter, LD.03.01.01)

TJC Definition of Disruptive Behavior

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Budin, W. 2017 ©

Healthy Workplace Bill 2003

• Creates a cause of action for those who can prove they were

subjected to malicious, harmful workplace bullying

• Liability upon employers – Held accountable

• Introduced in 25 states

• For Employers:

o Precisely defines an "abusive work environment"

• For Workers:

o Provides avenue for legal redress for health

harming cruelty at work

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• Intimidation or violence

• Inappropriate language or comments

• Sexual harassment

• Inappropriate responses to patient needs or staff requests

Four Categories of Disruptive Behavior

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Background

• Long recognized internationally

• Prevalence: 17-76% of RNs

• Physician to nurse,

• Patient / family to nurse

• Nurse to nurse

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Budin, W. 2017 ©

Background

• Little research done in US

• Structure of the healthcare system

• Incentives to NOT address bullying / disruptive behaviors

• Fear of liability

• Professional attitudes

• Normal part of job

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Theories to Explain Workplace Bullying

• Oppression

• Organizational

• Demand-Control theory

• Social Learning theory

• Gender

• Power

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Factors that may contribute …

• New to the organization or

profession

• The “this is how I was

treated” mentality

• Job conflict & Job stress

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Budin, W. 2017 ©

Factors that may contribute … (Continued)

• Individual characteristics

• Workload and resources

• Unit organizational culture

• Leadership

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• Communication perceived as “harsh”

• Passive Aggressive Behavior

• Infighting

• Backstabbing

• Broken confidences

• Failure to respect privacy

Characteristics

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Characteristics

• Scape-goating

• Exclusion

• Silence and withholding information

• Sabotage and undermining activities

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Budin, W. 2017 ©

Targets

• Anyone that differs from the group norm on any major

characteristic

-Gender

-Race/ethnicity,

-Personality traits

-Educational preparation

-Experience

-Professionalism

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Dysfunctional Unit

Culture

Victimization

Individuals TargetedWorsening

Bullying

No or Ineffective

Intervention

Spiraling Downward

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New Nurses Vulnerable

• New graduates are virtually all at risk

• Younger

• Less experienced

• Not knowledgeable

of cultural norms

• 2nd degree grads:

• Socially mature

• Clinically naïve

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Budin, W. 2017 ©

Impact

Psychological Symptoms

o Anxiety, irritability, panic attacks

o Tearfulness

o Depression, mood swings

o Loss of confidence

o Decreased ability to concentrate

o Diminished self-esteem

o Avoidance and withdrawal behaviors

o Increased use of tobacco, alcohol, and other substances

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Impact

Physical Symptoms

o Disturbed sleep

o Headaches

o Increased blood pressure

o Changes in eating patterns

o Gastro-intestinal upsets

o Loss of libido

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Workplace Impact

Behaviors

o Withholding

information

o Excessive criticism

o Insults

o Shunning

o Unreasonable

assignments

o Denied opportunities

Workplace Impact

• Impaired:

• Communication

• Collaboration

• Decision making

• Poorer performance

• Absenteeism

• Professional

disengagement

• Poorer retention

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Budin, W. 2017 ©

System Effects

• Substandard quality of care to

patients

• Negative impact on patient safety,

increased errors

• Lower staff and patient satisfaction

• Decreased teamwork and

productivity

• Potential for lawsuits, and

increased financial strain due to

related employee healthcare costs.

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Relationship to Quality of Care

Poorer

Satisfaction

Poorer

Quality

Care

Bullying

> Absenteeism,

Turnover

Bullying

Poorer

Quality Care

Poorer

Patient Outcomes

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Prevention Models

• Primary prevention: helps prevent the bullying from developing

• Requires the identification of those personal, interpersonal, and

environmental factors that contribute to bullying

• Secondary prevention: activities aimed at early problem detection

• Requires screening and intervention when bullying has begun, but is

still “under the radar” and/or long-term sequelae can be prevented or

ameliorated

• Tertiary prevention: prevention of progression and attendant suffering

after bullying is clinically obvious

• Often palliative in nature

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Budin, W. 2017 ©

INSTIGATOR(S)

Good-natured Intent

Caring

Environment

RECIPIENT(S)

Well receivedPoorly received

Mean-spirited Intent

Primary Prevention

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INSTIGATOR(S)

Good-natured Intent

RECIPIENT(S)



Resilience

to Bullying

Primary Prevention

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INSTIGATOR(S)

Good-natured Intent

RECIPIENT(S)



Subjective

Bullying

Secondary Prevention

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Budin, W. 2017 ©

INSTIGATOR(S)

Good-natured Intent

Identifying

Bullying

RECIPIENT(S)



Secondary Prevention

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INSTIGATOR(S)

Good-natured Intent

RECIPIENT(S)



Subjective

Bullying

Bullying Prevention Model

Identifying

BullyingResilience

to Bullying

Caring

Environment

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Caring Environment

• Caring - A learned, intentional, respectful act designed to maximize

another’s well-being

• Attitude

• Intent

• Context

• Competency

• Individualized focus

Central to quality patient care

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Budin, W. 2017 ©

Caring Environment & Quality Care

• Knowledgeable individuals

• Appropriate staffing

• Suitable physical environment

• Positive collaborative relationships

• Peer to peer interactions

• Interdisciplinary respect

• Administrative support

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Caring is not limited to our patients and their families

• Need to care for:

• Ourselves

• Each other

CARING BULLYING

Caring Environment and Quality Care

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Interventions

• Few tested evidence-based interventions

o Zero tolerance policies

• In NY state survey 55% of hospitals had policies

o Cognitive rehearsal (Griffin, 2004)

• Didactic teaching session with cue cards

o Team building

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Budin, W. 2017 ©

Prevention Strategies

• Awareness

• Cognitive Rehearsal

• Aggression management training

• Mentoring program

• Emotional Intelligence

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NYULMC Bullying Task Force (BTF)

• 20 Staff and Leadership

• Mission Statement

• Negative Acts Questionnaire-Revised ©

• iDevelop Awareness Program

• Champion Program

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Survey results:

Prevalence, attributes, and consequences

Bullying (prevalence) Bully (who were most frequently reported as the bullies)

62% ; 435 respondents self

reported themselves as having

experienced or witnessed bulling

in the workplace which primarily

occurred while in the staff nurse

role

58%

38%

34%

34%

Staff Nurse

Physician

PatientCare Techs

NurseManager

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Budin, W. 2017 ©

Survey results:


Personal Consequences

63%59%

50%47% 45%

40% 39%

31%

10%

20%

30%

40%

50%

60%

70%

80%

Loss ofConfidence

Anxiety Deminished Self-Esteem

Tearfulness Decreased abilityto Concentrate

Avoidance andWithdrawal

Distured Sleep Depression,Mood Swings

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Survey results:


Work Consequences

83%

72%

63%

37%

27% 25%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Decreased JobSatisfaction

Decreased Teamwork andCollaboration

Impaired Communication ProfessionalDiengagement

Poorer Performance Impaired Decision Making

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Survey results:

Prevalence , attributes, and consequences

59%

53%

42% 41%

30%

10%

20%

30%

40%

50%

60%

70%

Discussed withfamily/friends

Ignored the Bully Spoke to Nurse Leader Confronted the Bully Considered Resigning

Actions(How did you deal with the Bullying)

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Budin, W. 2017 ©

Survey results:


No action Reason for no action taken

34% 33%

27%25%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Belief Culture Wouldn’t Change Fear of Retailiation or Victimized Not Wanting to 'Rock the Boat' No Faith in Reporting Procedure

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Prevention Strategies:

Education and awareness campaign

and “BE NICE” champion program ©

B ullying

E limination

N ursing

I n a

C aring

E nvironment

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What to do when you, the Champion,

observes bullying on your unit….

48

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Budin, W. 2017 ©

Techniques for Champions:

Applying the 4 S’s

• Standby

• Support

• Speak up

• Sequester

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Conclusions

• The profession and the public cannot afford the effects of nurse

bullying in the workplace

• Bullying is an engrained problem and cannot be corrected by a

‘quick fix’

• Transformative leadership and a comprehensive evidence-

based approach are needed to ensure that respect, teamwork,

collaborative relationships are core values of the work

environment.

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Nurses as “Upstanders”

• “History has long been taught in terms of perpetrators and victims.

. . But it struck me that most of us live, actually in a different space,

and that is the space not between perpetrators and victims but

between bystander and, potentially, ‘upstander’” (Samantha Power, 2008)

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Budin, W. 2017 ©

Nurses as Upstanders

• Upstanders can speak for an entire group of people as in the

case of genocide or in smaller but no less significant ways

such as the acts taken by nurses for their colleagues and

patients.

• Rather than see nurses as victims, we must consider them

the pro-active seekers of change and justice that they are.

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• Consciousness Raising for Nurses

– Nurses must recognize that they are pro-active change

agents who engage in a process of making things right when

faced with workplace bullying.

– Nurses should facilitate the transformation from bystander to

upstander when bullying and other aggressive tactics are

perpetrated in the workplace.

Recommendations

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• The Role of Leaders:

– Leaders must ensure their actions are congruent with the values

of the health care organization.

– Leaders must encourage, and front-line nurses need to ask for

collective action with other nurses to discuss the challenges,

benefits, triggers and possible solutions to workplace bullying.

– Leaders must create a strategic plan for putting the knowledge

into action in local workplaces and in the worldwide arena.

Recommendations

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Budin, W. 2017 ©

Suggested References

Budin, W., Brewer, C., Ying-Yu, C., Kovner, C. (2013). Verbal abuse from nurse colleagues and work

environment of early career registered nurses. Journal of Nursing Scholarship, 45(3), 308-316. DOI:

10.1111/jnu.12033. Epub 2013 Apr 29

Brewer, CS, Kovner CT, Obeidat RF, Budin WC. (2013). Positive work environments of early-career

registered nurses and the correlation with physician verbal abuse. Nursing Outlook, 61(6), 404-416. doi:

10.1016.

Gaffney, D., DeMarco, R., Hafmeyer, A., Vessey, J., Budin, W. (2012). Making things right -- Nurses’

experiences with workplace bullying: A grounded theory. Nursing Research and Practice. Volume 2012,

Article ID 243210, 10 pages, doi:10.1155/2012/243210

Keller, R., Budin, W., Alllie, T. (2016). A task force to address bullying. American Journal of Nursing, 116

(2), 52-58.

Vessey, J. A., DeMarco, R. F., Gaffney, D. A., Budin, W. (2009). Bullying of staff registered nurses in the

workplace: A preliminary study for developing personal and organizational strategies for transformation

of hostile workplace environments. Journal of Professional Nursing. 25 (5), 299-306.

Documents

y Objectives - NJHAworkplace: A preliminary study for developing personal and organizational strategies for transformation of hostile workplace environments. Journal of Professional