International perspectives on workplace bullying among nurses: a review
Ms Susan L. Johnson, University of Washington, 1900 Commerce Street, Tacoma, WA 98402, USA, Tel: 360-943-1571; E-mail: email@example.com.
Purpose: This article examines the nursing literature on workplace bullying with the aim of reaching a better understanding of the phenomenon.
Background: Workplace bullying occurs in many occupations and workplaces, including nursing.
Methods: The following databases were used for the literature review: CINAHL, PubMed, Pro Quest and EBSCO host. Only articles in English were used. Articles from outside the nursing literature were also examined to gain a broader understanding of workplace bullying.
Findings: Workplace bullying is more than a simple conflict between two individuals. It is a complex phenomenon that can only be understood through an examination of social, individual and organizational factors. Workplace bullying has been shown to impact the physical and psychological health of victims, as well as their performance at work. Workplace bullying impacts the organization through decreased productivity, increased sick time and employee attrition.
Conclusions: More nurse-specific research is needed in this area. Research needs to be conducted in a systematic and uniform manner so that generalizations across studies can be made. The ultimate goal of this research should be to generate an understanding of this phenomenon so that solutions can be found.
Workplace bullying, often called lateral or horizontal violence in the nursing literature, is a phenomenon that is currently attracting considerable attention internationally. Workplace relations have been found to have profound impacts on the emotional and physical health and well-being of employees (Einarsen et al. 2003). Furthermore, nurses who are exposed to workplace bullying and hostility are more likely to leave either their current position, or nursing as a profession (Daiski 2004; McKenna et al. 2003; Simons 2006). Workplace bullying can negatively impact customer service, and can also jeopardize safe patient care (Farrell et al. 2006; Randle 2003; Rowe & Sherlock 2005).
Workplace bullying, or lateral/horizontal violence, is an international problem for nursing, as evidenced by research that has been conducted in Canada (Daiski 2004), the UK (Lewis 2006; Quine 2001; Randle 2003; Hutchinson et al. 2006), the USA (Griffin 2004; Simons 2006; Stanley et al. 2007), Australia (Curtis et al. 2007; Hutchinson et al. 2005; Rutherford & Rissel 2004), New Zealand (McKenna et al. 2003) Pakistan (Lee & Saeed 2001) and Turkey (Yildirim & Yildirim 2007). While bullying is the behaviour of an individual or a group, characteristics of organizations contribute to this behaviour (Ironside & Seifert 2003; Lewis 2006). Solutions to the problem of bullying lie in identifying and eliminating organizational factors that allow bullying to flourish (Hutchinson et al. 2006; Lewis 2006).
This article is the result of research that was done as an assignment for a master's level nursing class. To begin my research, I conducted a search for articles on the following databases: CINAHL, PubMed, Pro Quest and EBSCO host, using the keywords: workplace bullying, horizontal violence, lateral violence and mobbing. Twenty-five articles were found that related to nursing. Of these, only 17 were found to be useful for this article. To further understand the concept of workplace bullying, articles from outside of the nursing literature were examined. These articles were found from the references listed in the original 17 articles.
Definition of workplace bullying
There is no one agreed upon definition of workplace bullying. However, there is agreement that bullying is different from simple conflict in that it occurs more frequently, and for a longer period of time (Leymann 1996; Lutgen-Sandvik et al. 2007). Also, in workplace bullying, unlike simple conflicts, the victim is unable to defend themselves and bring about an end to the conflict because they have less power than the bully (Leymann 1996; Lutgen-Sandvik et al. 2007). In general, workplace bullying occurs when the victim ‘experiences at least two negative acts, weekly or more often, for six or more months in situations where targets find it difficult to defend against and stop abuse.’ (Lutgen-Sandvik et al. 2007, p. 841).
Workplace bullying was initially called ‘mobbing’ when it was identified in Sweden in the 1980s by the psychologist Heinz Leymann (Einarsen et al. 2003). In the 1990s, researchers in the UK began to study the same phenomena, which they labelled ‘bullying’ (Rayner & Keashly 2005). In the USA, researchers have focused on similar workplace issues, such as emotional abuse and generalized harassment, but have only recently begun to study workplace bullying in a systematic manner consistent with research that has been done in other countries (Lutgen-Sandvik et al. 2007; Rayner & Keashly 2005).
In the nursing literature, bullying is often defined as ‘lateral or horizontal violence’ (Curtis et al. 2007; Griffin 2004), ‘verbal abuse’ (Rowe & Sherlock 2005) or ‘workplace aggression’ (Farrell et al. 2006). This lack of a clear term and clear definition, makes it hard to compare the results of studies to each other, and to research on other occupational groups.
Manifestations of workplace bullying
Bullying behaviours can be very covert and subtle, making them hard to recognize as aggression (Einarsen et al. 2003; Rayner & Keashly 2005). Behaviours that constitute bullying include threats to professional status, such as belittling remarks, persistent criticism, humiliation, intimidation and inaccurate accusations (Moayed et al. 2006; Quine 2001; Zapf & Einarsen 2005). Bullies can threaten an individual's social status through verbal and physical threats and aggression, and by spreading rumours (Moayed et al. 2006; Quine 2001; Yildirim & Yildirim 2007). Social isolation, manifested through acts such as withholding information, not returning phone calls and emails and ignoring a person are also forms of bullying (Moayed et al. 2006; Quine 2001; Zapf & Einarsen 2005). The bullied individual might be subjected to an unreasonable workload, unrealistic deadlines and excessive monitoring of their work (Quine 2001; Yildirim & Yildirim 2007). Additionally, their professional status might be destabilized by giving them meaningless tasks, tasks that are beneath their level of competence or by removing key areas of responsibility from them (Moayed et al. 2006; Quine 2001; Yildirim & Yildirim 2007; Zapf & Einarsen 2005).
Power differences between the bully and the victim
In Leymann's (1996) original description of mobbing, he suggested that one of the features of this phenomenon that made it different from ordinary conflict was that it made the victim powerless, and therefore unable to bring about a successful resolution to the conflict.
At the beginning of the bullying experience, the victim and the bully might have equal organizational power, but as the bullying progresses, the victim might lose their power (Einarsen et al. 2003). However, sometimes a power differential exists at the onset of the conflict. This power differential may be based on the organizational positions of the victim and the bully, because of differences in knowledge and experience, or it may be based on the social dynamics of the workplace (Zapf & Einarsen 2005). Regardless of the source, the power imbalance leaves the victim of bullying in a situation where it is nearly impossible to defend themselves, and to bring about an end to the bullying (Einarsen et al. 2003; Lutgen-Sandvik et al. 2007; Zapf & Einarsen 2005).
Scope of the problem
Because of the difficulties in measuring exposure to bullying, some authors think that most studies underestimate the prevalence of the phenomenon (Zapf et al. 2003). In Scandinavian countries, researchers have estimated that 1–5% of the workforce has experienced workplace bullying (Zapf et al. 2003). In these countries, bullying is most often between co-workers with equal organizational power (Zapf et al. 2003). A different picture emerges from the research in the UK and the USA. In these countries, prevalence has been reported in the range of 10–38%, and a majority of the bullies are managers or supervisors (Hoel et al. 2001; Lutgen-Sandvik et al. 2007). Mikkelsen & Einarsen (2001) posit that Scandinavian countries have a lower incidence of workplace bullying because their workplaces are more egalitarian and feminist.
Zapf et al. (2003) reviewed the literature on workplace bullying and came to the conclusion that health care is one of the sectors that have higher incidences of bullying. Nurses have been included in other studies of workplace bullying, but few studies have examined bullying among nurses exclusively (Simons 2006). As mentioned in the previous section, studies on bullying among nurses have tended to define and measure the problem differently, making comparisons problematic.
In the USA, a survey of nurses in the state of Massachusetts found that 31% of the respondents had been bullied at work (Simons 2006). In the UK, in a study on community nurses, 44% of the nurses reported experiencing workplace bullying, and 50% reported witnessing workplace bullying (Quine 2001). Only 35% of the non-nursing staff in this same study reported experiencing workplace bullying (Quine 2001).
Rutherford & Rissel 2004 surveyed nurses who worked in a healthcare organization in New South Wales, Australia. In this study, which did not define how often bullying behaviours occurred, 50% of the respondents reported experiencing one or more bullying behaviours during a 12-month period (Rutherford & Rissel 2004). In another study in Australia that examined horizontal violence, 57% of respondents, who were nursing students, reported experiencing or witnessing horizontal violence at least once during the course of their training (Curtis et al. 2007). A study of mobbing among nurses in Turkey found that 86.5% of respondents had experienced mobbing behaviours at work at least once during the last 12 months (Yildirim & Yildirim 2007). It cannot be inferred that nurses in Turkey are more likely to be bullied than nurses in the USA, Australia or the UK because this study did not differentiate between respondents who had experienced these behaviours once, and those that had experienced them more frequently.
Consequences of workplace bullying
Workplace bullying has impacts on the physical and psychological health and well-being of victims (Leymann 1996). It also has impacts on the organizations in which the bullying occurs, causing, among other things, decreased job satisfaction, poorer performance and attrition (Quine 2001; Rowe & Sherlock 2005). Workplace bullying can also negatively impact patient safety (Farrell et al. 2006; Randle 2003).
It is known that stress negatively impacts health, and bullying is a very stressful situation that can cause lasting psychological and physical damage (Leymann 1996). Members of the workgroup who witness bullying, but are not directly bullied, also experience stress (Einarsen & Mikkelsen 2003; Lutgen-Sandvik et al. 2007). Exposure to bullying significantly increases rates of psychological distress, such as low self-esteem, anxiety, depression and suicidal ideation (Einarsen & Mikkelsen 2003; Kivimaki et al. 2003; Moayed et al. 2006). In a study of Turkish nurses, 10% of the respondents said they contemplated suicide because of workplace bullying (Yildirim & Yildirim 2007). Victims can exhibit symptoms so severe that it mimics those of post-traumatic stress disorder (PTSD) (Einarsen & Mikkelsen 2003; Leymann 1996). However, because of diagnostic criteria, they cannot be officially diagnosed as having PTSD (Einarsen & Mikkelsen 2003).
Workplace bullying can also impact the physical health of victims. Victims exhibit increased psychosomatic complaints such as dizziness, stomach aches, headaches, backaches, chronic fatigue and insomnia (Moayed et al. 2006; Yildirim & Yildirim 2007). Victims of bullying have been found to have higher incidences of chronic diseases and higher body mass index, but whether this is an outcome of bullying, or a risk factor for being bullied, is not known (Kivimaki et al. 2000). Prolonged bullying has also been associated with new onset cardiovascular disease. This effect might be partially explained by higher rates of obesity among victims of bullying (Kivimaki et al. 2003). Victims of bullying are more likely to miss work owing to illness; a study on a hospital in Finland found that bullying accounted for 2% of sick leave use (Kivimaki et al. 2000).
Bullying can affect the health of the entire workgroup. Employees who witnesses bullying report higher stress and lower job satisfaction than non-witnesses (Lutgen-Sandvik et al. 2007). The chronically hostile work environment created by the bullying situation, fear of becoming the next target and the inability to aid the victim lead to chronic low-level anxiety among witnesses of bullying (Einarsen & Mikkelsen 2003).
Social health and well-being, both on a professional and a personal level, are also affected by bullying. The victim of bullying ends up feeling socially isolated and ostracized at work, as if they have suffered a social death (Einarsen & Mikkelsen 2003; Lewis & Orford 2005). The victim's personality can undergo changes, and they can resort to inappropriate behaviours to cope with the bullying, which leads to further justification on the part of the group to avoid the victim (Einarsen & Mikkelsen 2003). Outside relationships suffer as the victim becomes increasingly preoccupied with workplace concerns, and victims feel they eventually exhaust their personal support networks (Lewis & Orford 2005). In short, ‘victimization due to bullying at work may not only ruin employees' mental health, but also their career, social status and thus their way of life’ (Einarsen & Mikkelsen 2003, p. 127).
Workplace bullying can have negative impacts on healthcare organizations that are already facing shortages of workers (Simons 2006). Students in Australia discussed how their experiences with horizontal violence in nursing school made them think about finding another career to pursue (Curtis et al. 2007). Most of the studies on workplace bullying among nurses have found that nurses who have been bullied at work discuss leaving either their current job, or nursing as a profession as a result of their negative experiences (Daiski 2004; Farrell et al. 2006; Griffin 2004; Lewis 2006; McKenna et al. 2003; Quine 2001; Rutherford & Rissel 2004; Simons 2006).
Effects of workplace bullying on patients
In a qualitative study, student nurses in the UK discussed how they became less compassionate towards their patients as a result of being bullied by the staff nurses (Randle 2003). In a study on workplace aggression among nurses in Australia, two-thirds of the respondents stated that they had made errors in their care because they were upset over an incident of aggression (Farrell et al. 2006). In a study of verbal abuse among nurses in the USA, 13% of the respondents said that this abuse caused them to make an error at work (Rowe & Sherlock 2005). New nurses in the USA reported being afraid to ask questions of other nurses because of a generalized climate of workplace bullying, a situation that could lead to these inexperienced nurses making mistakes (Griffin 2004).
Patient care is also negatively impacted by workplace bullying in that victims of bullying report decreased job satisfaction, that they are more easily upset, and that they have less energy (Quine 2001). Many nurses reported that they did not want to come to work because of bullying, and that because of this, they were less tolerant of their patients (Quine 2001; Rutherford & Rissel 2004). Workplace bullying leads to increased sick time, which can lead to short staffing, which can also negatively affect patients (McKenna et al. 2003; Rowe & Sherlock 2005).
Theorized causes of workplace bullying
Bullying was initially viewed as an aberrant behaviour that occurred between individuals within an organization. However, it is now recognized that the organization in which the bullying occurs plays an important role in enabling, motivating and triggering bullying (Hoel & Salin 2003). Employees can be also be bullied by an organization's policies and procedures (Liefooghe & Davey 2003). Finally, there are some scholars who believe that bullying is an inevitable outcome of the manner in which business is conducted in today's society (Ironside & Seifert 2003).
One characteristic of organizations that can encourage bullying is volatility. Bullying is more likely to occur when the workplace is being restructured or downsized (Hoel & Salin 2003; Ironside & Seifert 2003). Change is a constant in modern healthcare organizations, which makes nurses more vulnerable to workplace bullying (Hutchinson et al. 2006). In one study, nurses in Australia described how the change process was used as a tool to bully them, and also to hide this bullying (Hutchinson et al. 2005). Organizational pressures for nurses to increase their workloads, and to be more cost effective and productive, are also organizational features that contribute to a climate wherein bullying can flourish (Farrell 2001; Hutchinson et al. 2006; Lewis 2006).
Studies from occupations other than nursing have shown that bullying flourishes in workplaces that are characterized by negative and stressful environments, role-conflict and role ambiguity (Hoel & Salin 2003). While similar studies have not been done in nursing, many of the settings in which nurses' work, like emergency departments, intensive care units and the operating room are high pressure environments.
Leadership styles and workplace bullying
Two leadership styles, highly authoritarian and laissez-faire, are believed to create an environment in which bullying thrives (Hoel & Salin 2003). Management can also be the direct causes of bullying. In one study of nurses in the UK, 59% of the respondents said they were bullied by a manager (Quine 2001). Other studies from Australia (Hutchinson et al. 2005), New Zealand (McKenna et al. 2003), the UK (Lewis 2006) and the USA (Rowe & Sherlock 2005) have also reported that managers are sometimes the source of bullying behaviour. Some leaders adopt bullying tactics as part of their repertoire of methods to get their employees to work harder (Lewis 2006). Victims of bullying have stated that they felt that they were being bullied by managers who were using legitimate organizational policies and management practices in an abusive manner (Hutchinson et al. 2005; Liefooghe & Davey 2003). They have also stated they were intimidated during evaluations for behaviours such as ‘speaking up’ (Daiski 2004; Liefooghe & Davey 2003; McKenna et al. 2003; Quine 2001).
Some scholars argue that workplace bullying is a natural outgrowth of modern workplace environments (Hoel & Beale 2006; Ironside & Seifert 2003). Young (1990) says that the inherently hierarchical nature of most workplaces oppresses workers by removing their sense of control, thus rendering them powerless. Bullying by managers, and even peers, can be used as a means of controlling employee behaviour in order to create a more productive and cost-effective workforce (Hoel & Beale 2006; Hutchinson et al. 2006; Ironside & Seifert 2003). Studies from the UK, Australia and the USA, which show that an overwhelming majority of victims of bullying were bullied by their managers, support this view of bullying as a common management style (Ironside & Seifert 2003; Lutgen-Sandvik et al. 2007). These findings have chilling implications for workers; if their managers are involved in the bullying, it is less likely they will get organizational support to deal with it (Hoel & Beale 2006).
Nursing, under Florence Nightingale, developed as a very hierarchical system where submission was ‘expected, encouraged, indeed, demanded’ (Reverby 2005, p. 247). Nursing remains hierarchical in nature, and several authors cite this as a factor that has allowed and perpetuated a culture of bullying (Curtis et al. 2007; Daiski 2004; Farrell 2001). Bullying behaviours can be used to reinforce rules and norms, and to neutralize nurses who are challenging the status quo (Daiski 2004; Hutchinson et al. 2006). As such, bullying is used as a tool to maintain order and to reinforce existing power structures (Daiski 2004; Hutchinson et al. 2006).
Oppressed group behaviour
It has also been argued that bullying among nurses is an example of horizontal, or lateral violence, a behaviour that Freire (2000) described as violence among social equals who are members of an oppressed group. (Curtis et al. 2007; Daiski 2004; Lee & Saeed 2001; Simons 2006). The supporters of this theory believe that nurses are a traditionally oppressed group who have been rendered powerless by the medical establishment (Lee & Saeed 2001; Simons 2006).
Other authors argue that organizational factors, not oppression, lead to bullying among nurses (Farrell 2001; Hutchinson et al. 2006; Lewis 2006). As workplace bullying is a behaviour that is not unique to nurses, it stands to reason that they do not engage in bullying behaviours just because they are members of an oppressed group. If, however, bullying rates among nurses turn out to be higher than those of other professions, then the oppressed group theory might have some credence.
Perpetuation of workplace bullying
New nurses are socialized into the culture of bullying as students and new hires, and although they may have been victims of bullying, they often become the bullies as they gain power and status within the organization, (Curtis et al. 2007; Daiski 2004; Farrell 2001; Lewis 2006; McKenna et al. 2003). Lewis (2006) argues that bullying is not caused by psychological deficiencies within bullies, but that it is a behaviour that nurses learn from each other. This phenomenon is not unique to nursing; socialization into a culture of bullying has also been identified in other occupations (Hoel & Salin 2003). Nurses who feel powerless to change the culture, and who see bullying as antithetical to the principles of caring that they learned in school, often leave the profession within their first few years of practice (McKenna et al. 2003; Simons 2006).
Solutions to the problem of workplace bullying: implications for nursing practice
Unfortunately, as there has not been much research into the problem of workplace bullying, especially among nurses, no clear solutions to the problem have been found. As a first step, all health care leaders should become aware of the potential for bullying to occur within their organization, and should work to eliminate it. Policies should be put into place stating that bullying is not tolerated, and outlining how bullying incidents will be dealt with (Lewis 2006). Staff and management need to be educated about bullying, what bullying behaviours look like and how to deal with bullying, both from the standpoint of a target, and as a bystander (Lewis 2006; Stanley et al. 2007). Additionally, the organization needs to determine if there are any organizational factors, such as oppressive policies and procedures, or punitive evaluation methods, that inadvertently contribute to bullying, and work to create an environment in which bullying cannot reoccur (Hoel & Salin 2003; Hutchinson et al. 2006; Lewis 2006).
A few European countries, such as Sweden and Norway, have enacted laws that protect workers from acts of workplace harassment, such as ‘adult bullying’ (Yamada 2003). Laws cannot be the only solution to this problem, but they would at least give victims some legal support when they are unable to solve the problem through other means. Ultimately, the role of the organization in reducing bullying is central, as ‘bullying is far too widespread to be the work of a small number of pathologically disturbed individuals who can be removed from the workplace, monitored, or controlled so as to prevent them from bullying’ (Ironside & Seifert 2003, p. 396).
This article was not the result of an exhaustive and systematic review of the literature, so it is possible that there were some important studies that were missed. Additionally, all relevant studies that were found were included in this article; no attempt was made to judge them on the merits of their research.
While the exact extent of workplace bullying is unknown, it is probable that it has the potential to impact most workers at some point during the course of their working career – either as victims or bystanders (Einarsen et al. 2003). Bullying is detrimental to the physical and psychological health of both the victim and bystanders, which leads to increased sick time and absenteeism (Kivimaki et al. 2000). Bullying creates a negative and tense working environment, which in turn has impacts on patient safety, and nurse retention (Simons 2006; Stanley et al. 2007). Finally, workplace bullying has the potential to make the current nursing shortage worse, as nurses who are victims of workplace bullying are more likely to leave their jobs (Quine 2001; Simons 2006). In short, workplace bullying is a serious problem, and needs to be addressed.