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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)
Well receivedPoorly received
Mean-spirited Intent
Resilience
to Bullying
Primary Prevention
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INSTIGATOR(S)
Good-natured Intent
RECIPIENT(S)
Well receivedPoorly received
Mean-spirited Intent
Subjective
Bullying
Secondary Prevention
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Budin, W. 2017 ©
INSTIGATOR(S)
Good-natured Intent
Identifying
Bullying
RECIPIENT(S)
Well receivedPoorly received
Mean-spirited Intent
Secondary Prevention
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INSTIGATOR(S)
Good-natured Intent
RECIPIENT(S)
Well receivedPoorly received
Mean-spirited Intent
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:
Prevalence, attributes, and consequences
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:
Prevalence, attributes, and consequences
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:
Prevalence, attributes, and consequences
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.
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