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ABOUT THE AUTHORS Dr. Simons is Assistant Professor and Dr. Mawn is Professor and PhD Program Director, Depart- ment of Nursing, University of Massachusetts Lowell. The authors disclose that they have no signifi- cant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Shellie R. Simons, PhD, RN, 8 Marie Avenue, Sharon, MA 02067. E-mail: [email protected]. doi:10.3928/08910162-20100616-02

Bullying in the Workplace—A Qualitative Study of Newly Licensed Registered Nurses

by Shellie R. Simons, PhD, RN, and Barbara Mawn, PhD, RN

Bullying in the workplace is associated with negative job satisfaction and retention. It has also been found to have adverse effects on the health of employees. Using a qualitative descriptive design, this study examined the stories of bullying among nurses based on actual or witnessed experiences. One hundred eighty-four newly licensed U.S. nurses responded to an open- ended question on a survey about bullying mailed to their homes. Four major themes emerged that related to varying types of bullying behaviors, perceived causes of bullying, and the impact of bullying behaviors. The themes included structural bullying; nurses “eating their young”; being out of the clique; and leaving the job. Bullying is experienced firsthand and secondhand by nurses, and particularly by vulnerable, newly graduated nurses. Workplace bullying must be explored fully to develop effective strategies to eliminate it.

I t has long been acknowledged that some nurses engage in hostile behaviors toward other

nurses, as evidenced by the often re- peated expression, “Nurses eat their young” (Bartholomew, 2006; Meiss- ner, 1999; Rowe & Sherlock, 2005). This behavior has been reported pre- dominately through anecdotal stories among nurses and has only recently appeared in the research literature.

Bullying in health care workplaces has been identified in U.S. and inter- national research reports.

Various terms have been used to describe the interpersonal hostility that can occur in the nursing work- place, including bullying (Quine, 2001), horizontal violence (Duffy, 1995; McKenna, Smith, Poole, & Coverdale, 2003), and verbal abuse (Ferns & Meerabeau, 2008; Johnson, Martin, & Markle-Elder, 2007). Al- though the terms are often confused, subtle differences distinguish these behaviors.

Cox (1991) defines verbal abuse as any form of communication that nurses perceive to be harsh, con- demnatory attacks on them, pro- fessionally or personally. Bullying behavior in the workplace is a form of aggression that occurs when em-

ployees perceive negative actions directed at them from one or several individuals over time; employees have difficulty defending themselves against these actions (Matthiesen & Einarsen, 2001). An incident cannot be categorized as bullying unless there is a power gradient, perceived or actual, between the individuals involved (Zapf & Gross, 2001). Bul- lying is distinct from harassment in that it is not distinguished by sexual or racial motives (Pryor & Fitzger- ald, 2003).

Bullying differs from horizontal or lateral violence in several ways. Horizontal or lateral violence can occur as a single isolated incident, without power gradients between the individuals involved (i.e., the interaction occurs between peers in a culture that they share) (Duffy, 1995). In contrast, bullying is repeat- ed over at least 6 months. Horizontal or lateral violence and bullying do, however, share behaviors such as sabotage, infighting, scapegoating, and excessive criticism.

This descriptive study originated from a survey study that explored workplace bullying among U.S. nurses and the relationship of bul- lying to nurses’ intent to leave the workplace (Simons, 2008). These nurses had compelling stories to tell that exemplified the phenomenon of bullying in the workplace and its im- pact on nurses.

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BAckgROUnd Workplace bullying has signifi-

cant implications for nurses work- ing in the occupational health set- ting because workplace bullying has profound negative health effects on individuals. Research has also demonstrated that bullying results in considerable economic conse- quences for organizations (Einarsen & Mikkelsen, 2003; Hoel, Faragher, & Cooper, 2004). In a 2001 study of nurses in the United Kingdom, Quine reported that 8% of those experienc- ing bullying had used their sick time to deal with the problem. The direct costs to the employer included a low- er quality of work, higher turnover rates, and increased absenteeism. Indirect costs include those opportu- nity costs related to lowered employ- ee commitment, lack of individual discretionary effort, and time spent talking about the problem rather than working. Kivimaki, Elovainio, and Vahtera (2000) attempted to quantify the cost of bullying to the organiza- tion. They studied two Finnish hos- pitals and estimated that the annual cost of increased absenteeism as a consequence of bullying was close to £125,000 (approximately $191,489 U.S. dollars).

Recent studies have found that targets of bullying showed a variety of symptoms indicative of posttrau- matic stress disorder (Balducci, Al- fano, & Fraccaroli, 2009; Tehrani, 2004). Kivimaki et al. (2000) found that workplace bullying was associ- ated with a significant increase in sickness absenteeism. A 2003 study found a strong association between workplace bullying and subsequent depression, suggesting that bullying is an antecedent factor for mental health issues (Kivimaki et al.).

In 1976, Brodsky published the seminal work on bullying in the workplace, but it was not until 1990 that Swedish researcher Heinz Ley- mann (1990) began the systematic study of workplace bullying, con- ceptualizing it as “psychological terrorization.” Recently, published studies have explored workplace bul- lying from an international perspec- tive, including studies from Australia

(Hutchison, Jackson, Vickers, & Wil- kes, 2006), New Zealand (McKenna et al., 2003), Norway (Nielsen, Mat- thiesen, & Einarsen, 2008), and the United Kingdom (Lewis & Orford, 2005).

In the United States, Lutgen- Sandvik, Tracy, and Alberts (2007) studied the prevalence of workplace bullying among workers in several industries, including health and so- cial services, education, and finance. Only a few of the international stud- ies examined the effects of workplace bullying on nurses (McKenna et al., 2003; Quine, 2001). More recently, researchers have examined bullying among nurses in the United States (Felblinger, 2008), but a paucity of research related to bullying among nurses in this country exists (Fox & Stallworth, 2005; Lewis, 2006; Lut- gen-Sandvik et al., 2007).

Simons (2008) surveyed newly licensed U.S. nurses to measure the frequency and intensity of workplace bullying. The theory of oppressed group behavior served as the theoret- ical framework for the study (Fanon, 1963; Freire, 2000). One thousand surveys were mailed to a random list of U.S. nurses licensed in the state of Massachusetts. Five hundred eleven nurses responded. Although some studies using postal questionnaires have reported a response rate as low as 10% to 20% (Curtis & Redmond, 2009), this response rate of 54.4% was higher than the reported average response rate of 49.6% in a recent meta-analysis (Van Horn, Green, & Martinussen, 2010). The survey used the Negative Acts Questionnaire-Re- vised (NAQ-R) (Einarsen & Hoel, 2001), which contained 22 items re- lated to bullying and a 3-item scale that measured intention to leave the job from the Michigan Organiza- tional Assessment Questionnaire (Cammann, Fichman, Jenkins, & Klesh, 1981). In addition, the survey included the definition of bullying and then asked if the respondent had experienced or witnessed bullying at work during the past 6 months.

The results of the Simons (2008) survey revealed that 31% of the sample had experienced at least

two bullying behaviors on a weekly or daily basis from another nurse during a 6-month period based on the criteria of the NAQ-R bully- ing scale. The data revealed that as bullying scores increased, so did nurses’ intention to leave the orga- nization (Simons, 2008). However, the survey questions could not as- certain how bullying impacted their intention to leave. At the end of that survey, respondents were offered an open-ended section to add any com- ments related to the topic of bully- ing. One hundred eighty-four nurses shared their stories of bullying in their workplaces, which provided the qualitative data for this article.

RESEARcH dESign This article presents the quali-

tative findings from a survey study (Simons, 2008) examining work- place bullying among newly li- censed nurses. The analysis of the open-ended responses in the sur- vey followed the methods used in qualitative description to examine previously undescribed aspects of an experience (Kearny, 2001). The Institutional Review Board at the University of Massachusetts Boston approved this study. No names or other identifiers were used in ana- lyzing the results. In appreciation for participation, respondents who completed the survey were eligible to win one of five $50 raffle prizes.

Participants The population of interest was

newly licensed nurses in the United States. In accordance with Benner’s (2001) model of novice to expert, which indicates that 3 years is need- ed for a nurse to attain competence, the population included registered nurses licensed from 2001 to 2003 in the state of Massachusetts who had graduated from a diploma, asso- ciate degree, baccalaureate, or direct entry master’s program. Nurse man- agers and supervisors were excluded from the study. One hundred eighty- four of 511 registered nurses who responded to the mail survey wrote narratives at the end of the survey. One hundred thirty-nine wrote of

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being bullied at work and 14 oth- ers wrote of witnessing other nurses being bullied. The remaining par- ticipants wrote narratives that were not related to bullying. Respondents were predominately female (92%), with ages ranging from 22 to 61 years (M = 35.8 years). Forty-three percent of respondents had an asso- ciate degree and 37% had a bacca- laureate degree in nursing. The re- maining 20% had earned a diploma, a baccalaureate or a master’s degree in another field, or a direct entry master’s degree. The majority (85%) were staff nurses. The Table reveals similar demographics between the subsample who responded to the open-ended comment section and the entire sample of survey respon- dents. Seventy-one percent of the nurses who wrote of being bullied reported that they worked in hos- pitals and 12% worked in nursing homes.

Data Collection Data were collected via a

mailed survey during 6 weeks using the Tailored Design Method (Dill- man, 2000). This method consists of specified preparation and distribu- tion of survey materials to increase response rate. As noted, 36% (n = 184) of the original 511 survey par- ticipants shared their stories related to their personal and witnessed ex- periences of bullying.

Analysis The written narratives at the

end of the survey were transcribed verbatim and analyzed using con- tent analysis (Sandelowski, 2000). Content analysis “refers to the set of techniques that are used to identify patterns, categories and themes in recorded language” (Waltz, Strick- land, & Lenz, 2005, p. 239). After reading and rereading the narra- tives, the transcripts were entered into NVivo 7, a software package for qualitative research. Data reduc- tion was completed by writing in the margins and counting the frequency of similar comments. Two research- ers trained in qualitative research, one of whom is an expert in bully-

ing among nurses, independently re- viewed the comments to ensure that the stories fit the defining criteria of bullying. They then conducted a the- matic content analysis making com- parisons, noting patterns and expla- nations. The data were then coded according to themes and patterns that were found. Data saturation was noted by both researchers after ana- lyzing the first 100 responses; how- ever, all responses were included in the analysis.

FindingS Four themes describing different

aspects of bullying were identified from the analysis of the transcripts: structural bullying, nurses eating their young, feeling out of the clique, and leaving the job.

Structural Bullying The term structural bullying was

developed by the researchers to rep- resent perceived unfair and punitive actions taken by supervisors. These actions included scheduling, patient assignments and workload, or use

of sick and vacation time. Seventeen nurses wrote of consistently being given an unmanageable workload. For example, one respondent com- mented, “The only factor that may cause me to seek another job while still practicing as a registered nurse would be the unsafe staffing situation that exists consistently. Any time the acuity and patient load is so high that patients may be at risk, it creates strife among me and my coworkers.”

Others wrote of unfairness relat- ed to use of earned time. One wrote, “My manager yelled at me about my sick time in front of six other nurses.” Another wrote, “Being single with no children, I’m expected to take a holiday and mandatory shifts.” A 23-year-old nurse wrote, “My hos- pital is understaffed and I’m usually the first to be asked to work extra hours or overnight double because ‘I’m young’ and ‘I don’t need a lot of sleep.’”

Nurses Eating Their Young Nineteen nurses wrote com-

ments that included the phrase

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Table

comparison of Study Participants Original Survey

Study Qualitative Responses

Number of participants 511 184

Gender

Female 93.3% 92%

Male 6.7% 8%

Mean age (years) 33.1 35.8

Age range (years) 22-64 22-61

Educational background

Associate degree 38% 43%

Bachelor’s degree 45.2% 37%

Other 16.8% 20%

Primary practice role of staff nurse 93% 85%

Primary practice setting

Hospital 76% 71%

Nursing home 10% 12%

Other 13% 17%

Not reported 1%

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“nurses eat their young.” For exam- ple, one respondent commented, “In my first job as a registered nurse, I experienced such extreme hostility; it was like working in a pool with a pack of barracudas that ate their young.” Others shared similar sto- ries without using the actual phrase. A new graduate wrote, “Working as a new nurse is scary on its own. Add to this being afraid to ask questions for fear of being ridiculed and now you get one very unhappy nurse.” Similarly, another wrote, “In my first year as a nurse, I saw the major- ity of senior nurses were much too happy to keep information to them- selves and would rather see a new registered nurse fall flat on her face rather than give him or her the infor- mation to prevent it.”

The concept of nurses eating their young was noted by several nurses to begin in the formative years of the respondents’ education as a nurse. Several nurses wrote of their negative experiences as student nurs- es. One commented, “When I was in nursing school, we spent most of our time doing clinical work in a small community hospital. I found so much negativity in this environment that I considered quitting nursing school.” Another wrote, “Nursing school was a very different experience. I wit- nessed many registered nurses treat my classmates horribly, and that al- most prevented me from practicing.”

Feeling Out of the Clique Some of the respondents re-

lated bullying experiences to their feelings of alienation and not feel- ing part of the group. These nurses wrote of having difficulty fitting in when they perceived that they were different in any way. Differences may have been related to ethnic- ity, education, or the nurse not be- ing part of that group (i.e., being a per diem float or travel nurse). One nurse commented, “During my first pregnancy, because the charge nurse did not like me, I was assigned the most infectious patients (HIV, tu- berculosis, and hepatitis). When I complained, I was ridiculed and told, ‘Sorry, this is your assignment.’

When pregnancy complications de- veloped, I was put on light duty but nobody would help me. I was told, ‘Do your job or leave.’”

A 50-year-old new graduate wrote, “There were negative behav- iors in my first nursing experience, which was at a long-term care center: clique groups, rumors, sarcasm, and nurses not helping me with things I hadn’t encountered before. I was left alone with 40 patients constantly.” A 27-year-old Asian nurse wrote, “My pronunciation and English often gets ridiculed. I am one of the nurses from the Philippines who were hired 3 years ago.”

Leaving the Job Nurses wrote of leaving their

jobs as a result of being targets of bullying behaviors. Some talked of leaving their jobs and others wrote of leaving the profession. The ori- entation period seems to be a time when newly graduated nurses are particularly vulnerable to bullying. Thirty-eight nurses wrote of nega- tive experiences during the orien- tation period. A 24-year-old staff nurse in the operating room lament- ed, “During my 3 months of orienta- tion, I was bullied quite often. It was seen as proving yourself to your fel- low employees. I was often set up to fail purposely. I considered leaving almost daily.”

Another wrote, “This survey al- lowed me to share my experiences of my first years in the work force as a registered nurse. I worked in a hos- pital for 10 months. After that expe- rience, I seriously considered never working as a nurse again.”

A 28-year-old nurse wrote of her first year, “I currently work in an emergency room but recently left a cardiac floor in the same hospital be- cause of most of the nurses I worked with. The gossip and bullying made me leave. Many other new graduates have left this particular unit as well. The nurse manager was fully aware of the actions and attitudes on her unit but chose not to do much about them. It is a shame that new nurses are treated so badly. Every nurse was a new nurse once!”

diScUSSiOn The qualitative findings in this

study served as a method of trian- gulation for the survey data in the original study. The original study design did not aim to use a mixed- methods approach to examine bul- lying. At the outset of the study, it was not anticipated that 36% of the survey respondents would provide such rich narratives. However, de- spite these limitations in the original study design, the researchers chose to analyze the rich narratives us- ing qualitative methods, sharing the profound stories of experienced and witnessed bullying among nurses. The four major themes identified from the narratives clarified some of the suffering experienced and wit- nessed by nurses.

Simons (2008) reported an inter- esting finding in the original quan- titative analysis of the survey: 31% of the respondents met the criteria for experiencing bullying based on the responses to the NAQ-R scale, whereas only 21% responded that they had been bullied when asked and given the definition. This sug- gested a discrepancy in nurses’ un- derstanding of the construct of bul- lying and its impact on their work lives. Perhaps some of the nurses had the common perception of bully- ing as involving verbal taunts as op- posed to negative actions by those in positions of power over time. Many of those who shared their stories, however, reflected an awareness of this aspect of the definition. One of the four major themes captured the essence of these stories—structural bullying. Nurses wrote of unfair and punitive scheduling and pressure placed on them not to use earned sick or holiday time.

The theme of structural bully- ing has significant implications for nurses in general and occupational health nurses in particular. Nurses need to be aware that this type of subtle bullying (i.e., inequitable pa- tient assignments, shift allocations, or vacation allotments) needs to be prevented, identified, and dealt with fairly. Nurses who feel powerless in the workplace need to find their

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voice and recognize how to identify and resolve this issue. Occupational health nurses can provide nursing staff with the knowledge and actions to stop the perpetuation of this nega- tive culture.

The survey questions focused on a descriptive analysis of the preva- lence of bullying and its impact on leaving the profession. The two themes identified in the narratives— nurses eating their young and feeling out of the clique—helped to clarify how bullying can emerge in the work setting. The former is unfortunate and was expressed by many of the re- spondents. They experienced and wit- nessed this phenomenon as nursing students and as newly licensed nurs- es. In addition, many attributed their experience of bullying to not quite fitting in with the perceived clique. Racial and ethnic differences were identified within this theme, as were factors such as being pregnant or a float nurse. Implications for nurses in the educational setting as well as for nurses in the occupational health set- ting are evident in terms of preparing new nurses to address and deal with this potential form of workplace bul- lying and educating those in positions of power to prevent bullying and be aware of its potential impact.

The fourth theme identified in these narratives was related to the perceived impact of bullying on job retention. Although the survey tool measured bullying and intention to leave the job, it could not capture the direct impact of bullying and could not control for other factors that would impact leaving the job. Those participants who chose to write their stories commonly discussed the im- pact of bullying on their choice to leave a job and, in some cases, the profession. Occupational health nurses must be aware of the direct impact that bullying can have on job retention, in both the nursing pro- fession and other job sectors. When faced with such powerlessness, many employees choose to resign the posi- tion. Occupational health nurses can provide a vehicle to educate and sup- port those who are oppressed in the workplace.

None of the nurses wrote of actions that they employed to ame- liorate or eliminate the bullying be- havior. With the exception of one study (Griffin, 2004) that tested cognitive rehearsal as a strategy to deal with the negative effects of lat- eral violence, a paucity of research is available to assist administrators and nurses in occupational health with this problem that affects all as- pects of nursing. Both nursing staff and administrators need to be better educated about bullying so that they can more clearly identify the behav- ior both in themselves and in oth- ers. Future qualitative study designs need to specifically address this as- pect of the bullying cycle.

Although these qualitative find- ings shed light on a poorly understood phenomenon, several limitations of this study were identified. The major limitation of this study is that it was not designed originally with the rigor of a qualitative study that includes prolonged engagement in the field, in-depth personal interviews, or an avenue for member checking (Cre- swell, 2007). The authors acknowl- edge that the analysis of these data relied on qualitative methods, but the study was not designed with the stan- dards of a rigorous qualitative study.

Creswell (2007) suggests that at least two means of validation be incorpo- rated into qualitative analysis. Two measures used for this analysis in- cluded peer review or debriefing by the two authors of this report and the inclusion of data that provided a writ- ten rich description that could allow the reader to evaluate whether the findings are transferable to nurses in other settings.

A second limitation is that the open-ended section of the survey did not define bullying or ask for responses related to this definition. However, two researchers indepen- dently analyzed the data to ensure that the narratives included in the analysis did meet the criteria. Al- though the 184 respondents to the open-ended section of the survey had demographics similar to those of the entire survey respondent group, it cannot be implied that this group represented all of the survey partici- pants. In addition, another limitation is that the sample was drawn solely from nurses licensed in one state; it is unknown whether these results are typical of nurses in other parts of the country. Self-selection bias is a possible limitation to this study as well. Those with bullying expe- riences may have been more likely

AAOHN JOURNAl • VOl. 58, NO. 7, 2010

Bullying in the Workplace A Qualitative Study of Newly licensed Registered Nurses

Simons, S. R., & Mawn, B.

AAOHN Journal 2010; 58(7), 305-311.

1 Substantial research has shown that workplace bullying has profound negative effects on the health and well-being of individuals. These effects translate into considerable economic consequences for the organization.

2 Occupational health nurses can intervene directly to affect the health of employees and the profitability of the company. Through educa- tion and counseling, occupational health nurses develop programs to prevent bullying and provide support to those who experience it.

3 Occupational health nurses promote healthy working environments and positive organizational changes to ensure that bullying is not an accepted part of the culture.

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to respond to the survey in the first place and may not represent all new- ly licensed registered nurses in the United States.

Although additional future sur- veys can well serve to document the prevalence and incidence of bullying in varying settings among nurses with diverse levels of experience and edu- cation, rigorous qualitative research needs to be conducted to understand the roots of the phenomenon and its impact on nurses. In addition, inter- vention studies need to be designed to evaluate best practices and poli- cies to improve reporting and reduce the impact and existence of bullying among nurses.

cOnclUSiOnS This survey provided these

nurses an opportunity to share their personal stories about workplace bul- lying. The four themes identified put a new lens on the survey findings and expanded the understanding of bul- lying among the nursing work force. Several recent studies have validated that bullying exists in nurses’ work- places. These studies have shown that bullying is associated with job satisfaction, performance, and reten- tion, but little has been documented to examine these relationships in- depth. Additional research is needed to expand the knowledge about the factors that precipitate this noxious behavior and how to effectively treat and eradicate it.

Occupational health nurses can intervene in these issues that direct- ly affect the health of employees. Through research, educational pro- grams, and counseling, occupational health nurses can support and assist targets of bullying through difficult conflict situations. Bullying has been part of workplace culture since the beginning of professional nurs- ing and has been tacitly accepted by nurses for too long. Nurses are only just beginning to understand the root of this unfortunate phenomenon. Although this study adds to the un- derstanding of workplace bullying among nurses, additional research is needed to fully understand the phenomenon and develop effective

interventions to ultimately eliminate the behavior.

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