Notes for Nurse Managers

The Nurse Manager’s Role. Nurse Managers have an important role to play in preventing and correcting nurse-to-nurse bullying so as to keep as many nurses as possible in the nursing workforce. Visible participation of nursing leadership in addressing bullying fosters commitment, participation, trust, and open communication with front-line workers. Research has shown that managers who acknowledge and address workplace bullying were able to effectively help healthcare organizations retain good employees.

Nurse Leaders can help by:

(1) Establishing an ombudsperson within the healthcare organization to whom nurses can complain without fear of backlash.

(2) Promoting teamwork and team building among nurses to promote flexibility, sensitivity to the needs of others, and creativity within the group. Teamwork and productivity are enhanced when working group members have a strong sense of belonging and loyalty to both the group and their organization.

(3) Endeavoring to create a culture of change when implementing strategies to address nurse-to-nurse bullying so that the new environment requires an understanding of bullying and its implications and establishes guidelines for acceptable work behavior and peer interaction.

(4) Encouragingadoption of a “Dignity at Work Policy,” with sections on harassment, discrimination, violence, and bullying in order to highlight the employer’s commitment to providing workers with employment free from acts of bullying and intimidating behavior.

(5) Gaining knowledge about workplace violence and its causes, including discussion about it in staff meetings, conducting regular meetings with a designated committee, instituting a program to address the issue, then supervising its operation and success.

(6) Championing success to other units in order to lead the way for change.

Institutional Bullying. Corporate/institutional bullyingoccurs when bullying is entrenched in an organization and becomes accepted as part of the workplace culture. The costto such an organization is enormous. This type of organizational failure usually occurs when the workplace:

(1) Places unreasonable expectations on employees, where failure to meet those expectations means making life unpleasant (or dismissing) anyone who objects

(2) Dismisses employees suffering from stress as “weak” while completely ignoring or denying potential work-related causes of the stress

(3) Encourages employees to fabricate complaints about colleagues with promises of promotion or threats of discipline.

Signs of corporate and institutional bullying include failure to meet organizational goals; increased numbers of grievances, resignations or transfer requests; high absenteeism due to “sickness;” and increases in disciplinary actions. Nurse Leaders and Nurse Managers can establish benchmarks for each unit, monitor these statistics, identify units at risk, and plan appropriate interventions.

Measuring the Cost of Bullying. It is difficult to measure the exact cost of each bully to an organization because costs are both direct and indirect. While direct costs are tangible costs such as recruitment advertising or the use of agency nurses, indirect costs cannot be readily assigned to a specific activity or may be hidden - such as productivity losses or loss of institutional knowledge.There are few studies that have quantified quality of care and patient safety costs related to nurse turnover and retention. But a VHA study did report that organizations with low turnover rates (4%-12%) had lower risk-adjusted mortality and shorter patient lengths of stay than did organizations with moderate (12%-22%) or high (22%-44%) turnover rates. A later Canadian study reported negative effects associated with nurse turnover and communications that included medication management errors, compromised follow-up, client disengagement, illness exacerbation, and added burdens of caregiving for the families or patients.

A 1998 study at UNC Chapel Hill found that victims are likely to penalize the employer as opposed to tackling the bully directly, implying that the employee is holding the business accountable for the behavior and can take hidden, punitive and costly action against the offending employer:

12% of victims changed jobs

12% of victims intentionally decreased the quality of their work

22% decreased their work effort

28% lost work time just avoiding the bully

52% lost work time worrying about the person and the destructive interaction(s)

Measurable direct costs directly attributable to workplace violence include:

Increased sick leave and absenteeism

Reduced productivity

High staff turnover

Costly retraining and recruitment efforts

Low staff morale and demotivation

Costly law suits, increased disability and worker’s compensation claims

Damage to corporate image

Loss of staff/client/patient and family confidence

Increased medication errors

Increased levels of depression and suicide

Evaluating the Problem. A number of researchers have developed questionnaires that may be used to assess problems in the workplace. A review of some of their studies may help you to identify and understand the dynamics within your unit:

Leymann (1990) devised and administered the Leymann Inventory of Psychological Terrorization (LIPT). The questionnaire consists of 45 items grouped into types of hostile behaviors directed toward a victim as follows:

attacking a person's possibilities of communication

attacking a person's social relationships

attacking a person's social reputation

attacking the quality of a person's occupational and life situation

attacking a person's health

Leymann characterized behavioral styles that were often involved and can be recognized: negative communications, humiliating behaviour, isolating behaviour, frequent changes of task to punish someone, and violence or threat of violence.

Einarsen and Raknes (1997) developed the Negative Act Questionnaire (NAQ) in a study of harassment in the workplace. The questionnaire consists of 22 items, each written in behavioural terms with no reference to the term 'harassment'. The scale measures how often the respondent during the last six months has been subjected to a range of negative acts and potentially harassing behaviours. Factor analysis elicited the following groups of behaviors to look for: attacking the private person, social isolation, work-related measures, and physical violence.
Björkqvist et al (1994) developed the Work Harassment Scale (WHS) to assess how often workers have been exposed to 24 types of degrading and oppressing activities by their colleagues during the last six months. Items include: 'being unduly criticised', 'being shouted at loudly', 'being isolated', 'lies about you told to others'. Factor analysis revealed two sub-scales of covert or disguised aggression to be aware of: rational-appearing aggression and social manipulation.

Strategies for Coping as a Manager. There are specific strategies that you can use that have been demonstrated to be successful in managing workplace violence:

  1. Gain knowledge about Horizontal Violence and its causes, conduct regular meetings with a designated committee and institute a program to address this issue; supervise its operation and success. Call it by name, discuss it, and educate other workers at all levels.
  2. Identify specifically what constitutes bullying and be clear about the policy against this behavior
  3. Undertake a formal thorough analysis of your unit's culture.
  4. Ensure there is a process for dealing with this issue in your workplace and follow it. Provide a safe reporting mechanism for victims and witnesses.
  5. Have a policy and specific plan about harmonious workplace relations, support and encouragement of students, new staff members and staff.
  6. Foster an environment of open collaboration that includesexploring and healing of issues rather than faultfinding and blame.
  7. Cultivate a personal management style encouraging respect instead of fear.
  8. Take specific training in performance management and conflict resolution skills including role playing.
  9. Train staff members in conflict resolution skills, cognitive rehearsal technique and stress management techniques. Involve staff members in solving problems.
  10. Spend more time in problem units to assess the issues and assist victims to feel supported.
  11. Support workers' autonomy and initiative and promote a learning culture
  12. Provide education about processes to promptly report incidences of victimization- support and encourage people to do so.
  13. Monitor staff morale and address issues which negatively impact upon morale.
  14. Ensure that staffing is adequate, that rosters are fair and allocation to areas is fair within your unit/institution; ensure that all staff members have equal opportunity for advancement and education.
  15. Engage in self-awareness activities and in reflective practice. Highly authoritarian and laissez-faire styles are both believed to create an environment in which bullying thrives. Observe an individual who models a leadership style that has promoted a unit culture that you would like to encourage. Try to emulate their communications and managerial styles. Ask for feedback from staff about your management practices and not just from close associates.
  16. Institute open, honest and supportive dialogue through peer review - strategies that are process based, not personality based.
  17. Revise and articulate core values of institution and health care, making one core value a topic at each team meeting
  18. Engage in self care activities as above
  19. Adopt a zero tolerance policy and enforce it – hold bullies accountable for their actions
  20. Advocate with higher level managers on behalf of victims and witnesses

Studer (2008) suggests that nurse managers can incrementally change the work environment on their unit by examining areas for disruptive behaviors on a regular basis. A strategy called “rounding for outcomes” uses daily rounds to determine employees’ needs and concerns, using the time to recognize employees and their contributions to patient care an for establishing development opportunities for addressing deficits in care provided. It also provides a forum for addressing the potential for, or presence of, disruptive behaviors.

Strategies for Coping as a Business. Explore some of the following initiatives that may be appropriate for your organization to use for medical staff, management and staff member education:

Nursing Self-Governance Models

Multidisciplinary Task Forces

Employee Assistance Programs

Orientation And Mentoring For New Employees That Covers Violence

Safe Staffing & On-Call Requirements

Protection From Reprisal For Reported Infractions

Formal Policy Statements Regarding Violence Infractions

Briles J (2003) Zapping conflict in the health care workplace. SSM 9(6), 27. Available: 118&RQT=309&VName=PQD

Field, T. (2005) Working for a bully-free world. The Field Foundation. Available:

Jones C (2004) The costs of nursing turnover, part 1: An economic perspective. Journal of Nursing Administration, 34(12), 562-570.

MacIntosh J (2006) Tackling workplace bullying. Issues in Mental Health Nursing27, 665-679.

Minore B, Boone M, Katt M, Kinch P, Birch SMushquash C (2005) The effects of nursing turnover on continuity of care in isolated first nation communities. Canadian Journal of Nursing Research 37(1), 86-100.

Ruggiero V (2004) Beyond feelings: A guide to critical thinking (7th ed.). Boston: McGraw Hill.

Schulweis K (2010) Foundations for Positive Change in the Workplace. Availabl

Studer, Q. (2008). Results that last. Hoboken, NJ: John Wiley & Sons, Inc.

VHA Inc. (2002). The business case for workforce stability.Available: