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FROM THE FIELD

Nursing Workforce Retention: Challenging A Bullying Culture

Abstract

 
Discussions surrounding nursing shortages typically focus on recruitment, but retention is also a problem. Emerging research suggests that intimidation in the nursing workforce is a problem that planners need to deal with as part of an overall strategy aimed at maintaining a balance between supply and demand. This paper explores issues surrounding intimidation in the nursing workforce and looks at how one major teaching hospital in Australia attempted to address the problem.

Retention And Bullying

Top Retention And Bullying Case-Study Findings In Australia Concluding Comments NOTES

 
Lyn Quine’s study of the extent of work-place bullying in the United Kingdom found that 38 percent of nurses reported being bullied in the previous year and that 42 percent reported witnessing the bullying of nurses by other staff. She compares this with a study showing that one in eight non–health care staff experience bullying.³ Another British study of 462 midwives found that 46 percent reported being bullied and that of these, 55 percent were considering leaving within the year.⁴

Moreover, the intimidation factor seems to be more than a minor annoyance, and improving the way that management addresses such issues in nursing may be critical for improving retention. Terry Misener’s U.S. study found that one of the main components of job satisfaction for nurses was "intra-practice partnership and collegiality."⁵ But recent evidence suggests that management may turn a deaf ear to such complaints; Linda Aiken and colleagues’ study of 43,000 nurses across five countries showed that fewer than half of nurses are satisfied with the way that "administration listens and responds to nurses’ concerns."⁶

Reasons for bullying behavior. A British study suggests that nursing has always condoned intimidating behavior.⁷ The profession established itself at a time when public health was a reform movement, requiring its practitioners to educate the "lower orders" in health-related behavior for their own good. A bossy and controlling manner was seen as part of the nurse’s role. The first published academic analysis of the behavior as a negative characteristic, however, may have only appeared in 1984; this was in the form of advice to nurses on how to manage the stress associated with this kind of behavior.⁸

Because of the predominance of women in the nursing profession, subsequent attempts to explain intimidation in nursing focused on gender-based theories of the behavior of oppressed groups.⁹ More recently it has been proposed that intimidation may be the result of nurses who feel a lack of control attempting to gain control through bullying others.¹⁰ External pressures are often held responsible, such as health care workers’ need to find a scapegoat for errors.¹¹ The impact of the reform of the health care industry on staff is another reason cited for the existence of this behavior. The financing of hospitals on output-based formulae, for example, leads to greater levels of acuity in the hospital patient population and hence increased workloads for nurses. Increased stress is often the result, and this is said to contribute to an increased tendency for bullying in the nursing workforce.¹²

Responses by the nursing profession. There may well be many causes, but the evidence seems to demonstrate that bullying behavior has occurred within the nursing profession across a variety of institutional settings, including nursing faculties and professional bodies, for at least seventy-five years. The phenomenon appears to be integral to the culture of nursing and one that the profession is reluctant to address. In Christine Alavi’s words, it may be that "writing or speaking as a nurse when wanting to criticize or explore aspects of nursing can be a daunting experience...If one speaks critically or takes a questioning stance then one is positioned as disloyal, ungrateful and a bad nurse."¹³ It has been argued that the way forward is to focus on implementing strategies to reduce the opportunities for bullying behavior to occur.¹⁴ These strategies are not often specified, however.

Case-Study Findings In Australia

Top Retention And Bullying Case-Study Findings In Australia Concluding Comments NOTES

 
The pattern of emerging evidence suggests that further research on the bullying culture of nursing and approaches to modifying it could be a key component in efforts to improve nurse retention. I report here on the results of a case study in a large Australian teaching hospital, which for reasons of confidentiality I do not name. This hospital found that a bullying culture among its nurses was one of the main reasons why many nurses did not intend to stay in the hospital and, in many cases, in nursing generally. The hospital developed numerous strategies to address this and subsequently reduced its nursing turnover.

Nursing management at the hospital set up a focus-group research project in the late 1990s among its nurses who were still employed and those who had recently left, to determine the reasons for its low retention rate. Nurses identified many positive factors that that they expected and got from the hospital, but the overwhelming response concerned the extent of intimidation at the hospital and the organization’s seeming inability to acknowledge it as a problem or address it effectively. Victims of this behavior were present at every session conducted at every level. Some volunteered enormous quantities of written evidence supporting their claims and the alleged inaction of senior management. Several nurses claimed that their lives had been ruined by the oppression. One nurse claimed that a whole unit was in stress counseling because of a supervisor’s behavior, and still the administration did nothing. The supervisor regularly yelled at the nurse in front of other staff and patients, withheld information she needed to perform her duties, and excluded her from meetings and social functions. Others were given the "silent treatment" (talking to them through third parties, talking about them as if they were not present). Continual criticism of a person’s work, personal appearance, and voice was another type of behavior reported by nurses in the survey.

Often other staff witnessed these events but were not prepared to support their colleague for fear that one of them would be the next victim. Ignoring the victim’s behavior and distress seemed to be the way both staff and the organization responded to the issue.

Staff who were named in confidence to the research team as perpetrators of this behavior themselves cited intimidation from the next level. Every level appeared to be powerless to stop the behavior. This may be because it is "culturally institutionalized" rather than "perpetrated" by any one individual or group.¹⁵ Certain modes of behavior and attitude are the norm and are rarely questioned, and thus they become part of the culture of the organization, or the "way that we do things around here." "Successful" people are those who are able to adapt their behavior so that it is not in direct conflict with this culture. "Unsuccessful" people have difficulty with this, and many either opt out or become very stressed.

Staff at this hospital often felt that they had no one to go to when they needed help because of the seemingly covert acceptance of bullying. Some also felt that they were blocked by senior management from pursuing their issues through the normal channels such as the various grievance procedures in place. Whatever measures were there for dealing with this issue were clearly inadequate.

There appeared to be a style of management within nursing at this hospital that was based on fear rather than respect. There was an impression that nurses were tolerated rather than valued, that they should keep their heads down and not threaten those above them by disagreeing with them, raising problems with them, or becoming more educationally qualified than they were. Senior management appeared rarely in the wards and were seen as inspectors to fear rather than supporters, advocates, and leaders.

Nursing management responded promptly to the issues raised. They convened a workshop and confronted behavior that most acknowledged had been there for a long time but was never discussed. Several of them took personal responsibility for the situation, and a consensus was reached that they were going to actively bring about change by developing, publishing, and implementing their strategies.

One of the first such strategies was to involve the next level of nursing management in the problem-solving process. Full-day workshops were attended by more than 90 percent of nursing supervisors to receive feedback on the research and to develop compatible strategies for their areas. Each workshop was addressed by the hospital’s nursing leader, who explained her response and feelings on the research findings and asked the groups for their help in addressing the findings. For many staff, this leader appeared in a new light as someone willing and able to acknowledge shortcomings in the profession and in this specific organization. Others were shocked to discover that they were contributing, inadvertently or otherwise, to a bullying culture by their actions or inactions. A few denied the results and expressed the view simultaneously that nursing was always "like that" and if nurses couldn’t take it, they should leave. Many others felt empowered to promote a different way of doing things in their own spheres of control and to remind more senior management of their commitment to change. They subsequently began to implement some of the strategies produced at the workshop.

For example, the nursing leader of operating theatres commissioned more research into issues specific to teamwork in this area and involved many staff in solving problems related to these issues. A policy document on bullying and intimidation was developed. There was some reluctance, however, to specify the sorts of behavior that would not be tolerated, and instead the policy referred to the general "rights" of individuals to be treated fairly and with respect.

Effective antibullying practices must include a statement of exactly what constitutes bullying, because often the perpetrators do not define their behavior as problematic in any way.¹⁶ This is certainly true from the experience of the research team confronting the issue in the workshops: Most staff were readily able to describe bullying behavior, but a sizable number failed to recognize that this sort of behavior was problematic. The reluctance on the part of the nursing management drafting the antibullying policy to specify exactly what bullying behavior was could have arisen because of their often-expressed desire to "confine" the issue to nursing. Acknowledging the existence of the behavior more generally by describing it within a document for hospitalwide consumption was possibly too threatening at the time. Herein may lie a great deal of the problem: Issues such as this, within both organizations and professions, need to be brought out into the open in a nonblaming way with a focus on the future.

On a wider scale, it may be necessary to include the ability to manage instances of intimidation by staff in the competency requirements for nursing leaders and reflect this in the education of nurses. The general competency of managing a team could ostensibly cover this, but unless the issue is specifically targeted, changing attitudes and behavior in the profession as a whole may be impossible. It may be necessary to provide role models of leaders who actively address bullying behavior and to equip those coming into nursing with the skills to both resist and tackle bullying.

Nursing supervisors in the case-study hospitals attended training in performance management and conflict resolution with a specific reference to bullying behavior. Also, the nursing leaders felt that their having a greater presence in the work areas was an important step to encouraging staff to feel that they would be supported and that issues would be dealt with promptly. Senior staff scheduled "ward time" into their working days and published a newsletter with information about the nursing leaders and what they were doing.

The outcome one year later was a decrease in the nursing turnover rate. This rate was defined as the proportion of original employees in a twelve-month period who left the organization. In the three-year period before the strategies were implemented, the average turnover rate was 28.4 percent. One year later this dropped to 22 percent; in the three subsequent years it has averaged 21.9 percent. Other factors may have been involved in this reduction, but the result nevertheless was encouraging.

Concluding Comments

Top Retention And Bullying Case-Study Findings In Australia Concluding Comments NOTES

 
Although a bullying culture in nursing is not often specifically referred to in large-scale studies of hospitals’ nursing dissatisfaction and retention strategies, it is clear that tackling this issue may be critical. The literature indicates that this sort of nursing culture may be more prevalent than the profession may care to admit. Nursing leaders can go some way toward tackling a culture of intimidation by (1) developing more open communication and increased access to nursing senior management; (2) ensuring that nursing supervisors receive adequate nonclinical training for their role; (3) ensuring that competency standards refer specifically to managing bullying and that these standards are maintained through an effective performance management system; (4) providing accessible professional development opportunities for all staff; and (5) developing policy on bullying in the work-place and conflict resolution mechanisms.

All of these strategies may decrease the possibility that a bullying culture will continue to find expression and that nurses’ perceptions of a lack of responsiveness by managers may be overcome. However, the existence of such a culture needs to be recognized and challenged before the strategies can become effective. The phenomenon has attracted empirical research only recently, and it may be that nurses themselves have not accepted the need to address this issue within their profession. In this case study, the nursing leader had the courage to publicly admit to the existence of a culture that condoned bullying behavior and to commit to changing this culture.

There are myriad ways of subverting implementation by stakeholders who feel the need to maintain the status quo. Many have firm views on the necessity for younger nurses to endure what they themselves had to endure in their "training" for the profession. Delaying action until these nurses leave the system is a mistake. New nurses finding that to survive and succeed one needs to be able to throw one’s weight around in this fashion may constitute a pool of new recruits to the culture. Many more, however, are deciding that this is not for them. Health care facilities cannot afford this loss. Tackling the nursing shortage requires action on both attracting recruits and making it easier for them to stay.

Editor's Notes

 
Stella Stevens is senior lecturer at the School of Public Health, Griffith University (Logan Campus), in Queensland, Australia. She was chief investigator of the case study reported here.

The author acknowledges the courage of staff who participated and thanks them for their contribution. Any errors of intepretation are the author’s own.

NOTES

Top Retention And Bullying Case-Study Findings In Australia Concluding Comments NOTES

 

1. M. Foley, "American Nurses Association Acts to Unite Nursing Profession over Staffing Crisis, Emerging Shortage," ISNA Bulletin 27, no. 4 (2001): 12–30.
2. J. Iliffe, "Nursing Workforce Issues: An International Perspective," Australian Nursing Journal 9, no. 1 (2001): 1–2.
3. L. Quine, "Workplace Bullying in NHS Community Trust: Staff Questionnaire Survey," British Medical Journal 318, no. 7178 (1999): 228–232.[Abstract/Free Full Text]
4. R. Hadikin and M. O’Driscoll, The Bullying Culture (London: Butterworth Heinemann, 2000).
5. T.R. Misener, "Development of Misener Nurse Practitioner Job Satisfaction Scale," Journal of Nursing Measurement 9, no. 1 (2001): 91–108.[Medline]
6. L.H. Aiken et al., "Nurses’ Reports on Hospital Care in Five Countries," Health Affairs (May/June 2001): 43–53.
7. Hadikin and O’Driscoll, The Bullying Culture.
8. E. Smythe, Surviving Nursing (Menlo Park, Calif.: Addison-Wesley, 1984).
9. S. Roberts, "Oppressed Group Behaviour: Implications for Nursing," Advances in Nursing Science (July 1983): 21–30.
10. M. Lewis, "Bullying in Nursing," Nursing Standard 15, no. 45 (2001): 39–42.
11. M. Hampshire, "Are Nurses Their Own Worst Enemy?" Nursing Times 96, no. 38 (2000): 10–11.[Medline]
12. L. Sunderland and L. Hunt, "Bullying: An Unrecognised Road Much Travelled by Nurses," Australian Nursing Journal 9, no. 2 (2001): 39–40.
13. C. Alavi, "Good Nurse, Bad Nurse," Journal of Advanced Nursing 21, no. 2 (1995): 344–349.[Medline]
14. G.A. Farrell, "From Tall Poppies to Squashed Weeds: Why Don’t Nurses Pull Together More?" Journal of Advanced Nursing 35, no. 1 (2001): 26–33.[Medline]
15. C. Alavi, "Good Nurse, Bad Nurse," Journal of Advanced Nursing 21, no. 2 (1995): 344–349.[Medline]
16. P. Gorman, "Bullying in the Workplace" (Presentation to the Safety Institute of Australia Fifth Annual Conference, Queensland, 1997).

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