Bullying in Health Care

Susan Johnson, PhD, RNUniversity of Washington, Tacoma

1. Describe how regulatory agencies and healthcare organizations discuss the management of workplace bullying.

2. Describe how hospital nursing unit managers discuss their efforts to manage workplace bullying.

3. Describe how managers discuss their organizations’ policies.

4. Discuss how organizations can more effectively manage workplace bullying.

What is workplace bullying Negative acts directed towards one or more people in the

workplace Frequent: daily, weekly, monthly Persistent: duration of months to years Power differential between perpetrator & target Results in harm to the target

Workplace Bullying Examples of bullying behaviors

Personal attacks: gossip inappropriate jokes demeaning comments social exclusion

Work-related behaviors: “silent treatment” or withholding information sabotaging work excessive work with unrealistic deadlines

Physical bullying: pushing invading space intimidation through body language

Prevalence General population of workers (worldwide): 10-15%

(Nielsen, Matthiesen, Einarsen, 2010) General population of American workers: 10-12%

(Workplace bullying institute, 2010) Nurses worldwide: 39.7%

(Spector, Zhou & Che, 2013) Bullying among nurses in US & Canada:

21.3% daily & 57.9% occasionally (Berry, et al., 2012) 27% daily or weekly (Johnson & Rea, 2009) 31% daily or weekly (Simons, 2008) 33% daily or weekly (Laschinger, et al., 2010)

Outcomes of bullying Stress-related illnesses: depression, anxiety, fibromyalgia,

backaches, headaches, gastrointestinal problems, cardiovascular issues (Neilsen & Einarsen, 2012)

Turnover of staff, burnout, decreased commitment to job (Neilsen & Einarsen, 2012)

Medical errors (Wright & Khari, 2014)

Why do healthcare organizations need to address workplace bullying? : The business case Decreased productivity: estimates are this costs

$11,581/nurse/year (Lewis & Malecha, 2011)

Lost workdays: workplace mistreatment costs $4.1 billion or 5.5% of sickness absenteeism in 2010 in the US (across all sectors) (Asfaw, Chang & Ray, 2014).

6% of sickness absenteeism in healthcare sector attributed to workplace bullying (Asfaw et al., 2014)

Cost associated with medical errors (Wright & Khatri, 2014)

Managing bullying: two perspectives Targets of bullying frequently report that managers &

organizations do nothing to help them resolve bullying, or their efforts make the problem worse (Namie & Lutgen-Sandvik, 2010; Dzurec, 2013; Gaffney, 2012)

Managers say they have an ethical responsibility to address workplace bullying (Lindy & Shaefer, 2010) But did not always know if their efforts are successful Some report organizations are not supportive of their efforts

What do we know about how healthcare organizations are currently addressing bullying? No legal mandate to address bullying.

Joint Commission mandate to address disruptive behaviors.

Survey of staff nurses in NY State: 61% : no policy in their organization29% : policy was not enforced (Sellers et al., 2012)

Survey of managers in NY State43% : no policy in their organization42% : policy is enforced15% : policy is not enforced (Sellers et al., 2009)

Aim: Describe how hospital unit managers, organization documents & regulatory agency documents discussed workplace bullying.

Goals: Learn how they say they manage workplace bullying Get some insight into why targets say organizations and

managers’ efforts are not effective

Methods Recruited managers via advertisement & snowball

sampling Contacted healthcare organizations where managers

worked to obtain policies related to workplace bullying Searched websites of OSHA, NIOSH, L&I & The Joint

Commission (JC) for documents related to workplace bullying (or similar behaviors)

Analyzed using Critical Discourse Analysis (Fairclough, 2003, 2008, 2009)

Sample 15 hospital nursing unit managers 14 documents from 6 of the 7 healthcare organizations in

which managers worked Policy and procedures (11) Codes of Conduct (3) Performance Review (1)

8 documents from OSHA, NIOSH, L&I & JC

Findings: Terms used to describe behaviors in documents Terms used to describe bullying-type behaviors:

disruptive behavior (12 documents) harassment (9 documents) bullying (5 documents)

Bullying never clearly defined Exception - SHARP Report: Workplace Bullying and Disruptive

Behavior: What Everyone Needs to Know (L&I, 2011) This document presented disruptive behavior, harassment &

bullying as separate concepts

Findings: Terms used to describe behaviors (cont.) OSHA, NIOSH, L&I

Disruptive behaviors, harassment & bullying classified as workplace violence

Emphasized that there is no legal requirement for organizations to address bullying, but encouraged them to do so

JC Discussed disruptive behaviors, no mention of bullying Require hospitals to address disruptive behaviors as part of accreditation This requirement has been interpreted as a mandate to address workplace

bullying (Johnston, 2009; Sellers, 2009)

Healthcare organizations Used “disruptive behaviors”, “harassment” & “bullying” interchangeably

Managers: terms used Preferred the term bullying over disruptive behavior or

harassment Tended to use euphemisms when talking with staff

Several specifically said they disliked the term “disruptive behavior” “Because disruptive behaviors could be anything, like talking

on cell phones, it is too broad” One was unfamiliar with this term, and said it hindered

her ability to find policies that addressed behavioral issues

Workplace Bullying: Occupational Safety vs. Patient Safety Discussions of negative effects of behavior on patient

safety predominated in documents issued by JC & the healthcare organizations.

Occupational safety: predominant in OSHA, NIOSH & L&I However, evidence suggesting that workplace bullying is an

occupational hazard was not mentioned. Healthcare organization documents did not specifically

address negative outcomes of bullying on employee health & how these might be mitigated.

Managers: Occupational safety vs. patient safety Discussed how workplace bullying can make their staff sick.

“People would call in sick because they didn’t want to work with [the bully]”

Also acknowledged that workplace bullying can affect patient care.

Tension between perpetrators of bullying as “clinically competent” and “you can’t be a really good nurse if you’re doing that”

How managers characterize bullying behaviors Interpersonal: related to conflict or personality difference

between the perpetrator & the target

Intrapersonal: related to personality traits, inability to deal with stress, of the perpetrator

Indeterminate situations: Is it bullying?

What managers said they did when bullying occurred Interpersonal: told the targets or other staff they needed to

confront perpetrator, or “work it out” Managers facilitated or mediated conversations Offered role playing opportunities to practice confrontations

Intrapersonal: managers would take responsibility Counseling of perpetrators Referral to EAP or other counselling services Progressive guidance & possible termination

Indeterminate: Investigation

How managers characterized dealing with workplace bullying Time consuming: lengthy process that often involved

union action (grievances) During this time, targets & other staff often leave feeling

nothing is being done Draining Not much support from others Very supportive human resources Perpetrator tried to bully them into dropping action Inheriting “problem children” from other managers

What policies said about manager & staff roles Managers should initiate informal or formal action (“based on

managers’ discretion”) Did not specify what actions managers could take Did not specify when to pursue formal action

Staff are encouraged, but not required to confront perpetrators (2 organizations) All of the managers expected staff to confront perpetrators For interpersonal bullying; managers said they would not take action

if staff had not first tried to talk with perpetrator

Managers are responsible for informing staff of policies Only 2/15 managers said this was their responsibility.

What managers said about the policies Not helpful (7/15)

Doesn’t define behaviors Doesn’t tell you how to respond No one refers to it Union actions override the policy

Very helpful (5/15) Defines behaviors Vagueness allows you to use it for multiple types of behaviors Helpful guide for disciplining I use it to discuss issues with staff

Never heard of it (3/15) Not mentioned in recent workshop on bullying & disruptive behaviors Wouldn’t know where to look for it (because of the use of term “disruptive

behavior”) “I don’t think we have one”

Discussion of findings: Managers Some of managers actions can give targets the impression

they are doing nothing Investigation Length of time to get behaviors to stop or to fire perpetrators Onus on targets & staff to report back to managers if bullying

continues Managers using policies in an ad hoc manner Managers reinterpreting policies Policies not consistently enforced

Discussed “other managers” making excuses for clinically competent nurses who engage in bullying behaviors

Discussion: Organizational Policies Not clearly written. Managers do not know about them. Managers do not use them. Are not part of the general discourse of the organization.

Discussion of findings: regulatory agency documents No acknowledgement of recent research on negative

health effects of workplace bullying.

No mandate for organizations to address bullying.

Joint Commissions’ mandate to address disruptive behavior does not adequately address workplace bullying.

Suggestions for change in regulatory policy US should join the other countries that recognize workplace

bullying as an occupational hazard (e.g., Sweden, Denmark, Norway, Finland, Australia, France, parts of Canada (Ontario, Quebec & British Columbia))

Occupational health practitioners can support legislative efforts such as “The Healthy Workplace Bill”, can encourage regulatory agencies to recognize workplace bullying as an occupational hazard

Occupational health practitioners can encourage their organizations to address bullying under OSHA’s General Duty Clause (Harthill, 2010)

Suggestions for change in organizational practice Clear, concise policies Seek feedback from end-users of policies Ongoing education re: workplace bullying & policies Periodic surveys of prevalence of workplace bullying

Clear & concise Introduce the problem Define terms Give examples of behaviors Clearly define roles and responsibilities in managing

bullying List consequences

Formal and informal

Elements of successful policies

Sample Introduction

Statement of why bullying is a problem that needs to be addressed

“This organization is committed to providing a healthy workplace for all employees. Behaviors such as workplace bullying are unacceptable and will not be tolerated in our organization. Workplace bullying is harmful to employees and negatively impacts patient care.”

Example of definition of bullying for policy

Workplace bullying is persistent, malicious mistreatment that intimidates, offends, degrades, humiliates and harms an employee. Examples of bullying behaviors include, but are not limited to…”

Examples of behaviors

Glaring or non-verbal displays of hostility Exclusion or social isolation Excessive monitoring or micro-managing Work-related harassment (overload, unrealistic deadlines,

meaningless tasks) Being held to a different standard than co-workers Personal attacks Unwelcome touching Repeated put-downs or offensive jokes Spreading rumors

What bullying is not Appropriate disciplinary or management Constructive or fair criticism of another’s work (e.g. done

in private, clear performance goals, clearly & fairly documented, allows for grievances)

Roles and responsibilities of staff Be aware of policies Be cognizant of impact of their behaviors on others Be open to feedback & willing to change behaviors Report incidents to ….(list contact information. Include

how to report a supervisor who is bullying). Be willing to document behaviors.

Confronting perpetrators?

Roles & Responsibilities of Management Role model appropriate behaviors Be aware of policies Promote awareness among staff; initiate conversations

about appropriate behavior Take informal or formal action to complaints of bullying

or observed behaviors Follow up on all complaints

Examples of informal actions

“Managers are encouraged to use informal actions if appropriate to manage bullying” such as: Counseling of perpetrators Referring perpetrators (& targets?) to classes (e.g. crucial

conversations, anger management) Referral of targets to EAP, employee health if needed Mediated discussions

Formal process Progressive guidance

Some resources stopbullyingtoolkit.org Workplace Bullying Institute: http

://www.workplacebullying.org/ Washington Department of Labor & Industries:

http://www.lni.wa.gov/safety/research/Workplacebullying/Default.asp

Thank you! Questions at the end of all presentations