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) Encouraging adoption 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 bullying occurs when bullying is entrenched in an
organization and becomes accepted as part of the workplace culture. The cost to 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:
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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
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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:
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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 includes exploring 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 laissezfaire 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
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118&RQT=309&VName=PQD
Field, T. (2005) Working for a bully-free world. The Field Foundation. Available: www.thefieldfoundation.org/
Jones C (2004) The costs of nursing turnover, part 1: An economic perspective. Journal of Nursing Administration, 34(12), 562570.
MacIntosh J (2006) Tackling workplace bullying. Issues in Mental Health Nursing 27, 665-679.
Minore B, Boone M, Katt M, Kinch P, Birch S & Mushquash 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. Availablhttp://www.hirecentrix.com/foundations-forpositive-change-in-the-workplace-part-1.html
Studer, Q. (2008). Results that last. Hoboken, NJ: John Wiley & Sons, Inc.
VHA Inc. (2002). The business case for workforce stability. Available:
www.healthleadersmedia.com/pdf/white_papers/wp_vha_120103.pdf.