I need a peer review [b]for a research paper I am working on for English 102. Any feedback[b] would be appreciated. For some reason it will not upload. So here it is
Diverse and technical, the nursing profession is an invaluable resource and is considered the cornerstone of the healthcare system. Many fill a backpack with enough books to equal two twenty pound weights. They trundle off to a multitude of classes feeling like a fish out of water after being enmeshed into a subject as foreign as nuclear fission. They sacrifice many hours with family and friends, just to gain a license to provide care to many types of patients in multiple different environments. The last thing they expect as they report to work is psychological harassment, intimidation, verbal abuse and even hostility such as aggression and violence. Despite present anti-bullying policies in the workplace, bullying is still prevalent due to employee fear of retribution, lack of supervisor recognition or attempt at prevention and lack of prevention policies utilized.
Within the last 10 years it is estimated that the nursing shortage will be an estimated 4.3 million with a 20% increase over the next 20 years. One third of the nurses are over the age of 50, leading to more nurses retiring than graduating from nursing programs. Turnover rates of 34% has further led to shortages with emotional exhaustion stemming from bullying, leading to burnout being cited as the cause.
There are many descriptions and definitions of bullying. Some address the physicality and the psychological aspect, while others address locations and time-frames. While these descriptions of bullying are important, the focus of effects and prevention will be addressed in this paper. Definitions aside, to begin to understand the development of bullying and violence in healthcare, one must first start with the past. Traditionally bullying has been associated with kids on the playground. Today current thinking has shifted to a different description. The bully of today is described as intelligent with good social and manipulative skills, having the ability to gather supporters around them, and creating an audience that rarely challenges their act. The subject of horizontal violence (also known bullying) in healthcare has been analyzed and numerous articles written since the 1990's. For years the industry has supported a tolerant and "blind eye" attitude towards the violence of nurses against other nurses."Nurses eat their young" is usually perceived as an inevitable consequence of the profession." (Lally 1). Some experts surmise that the traditional subservient role that nurses have played with physicians has influenced a transference of conflict. As in a hierarchical society, those with low self-esteem exacerbate the cycle, and Instead of responding with empathy as would be expected of the profession, indifference and evasion was predominately exercised, further permitting the continuance of abuse. With a victim description of unproductive, hesitant, and demonstrating inadequate community skills, one would think the victim would be incapable of defending themselves against such actions. A study found that many nursing students who were victims of workplace violence later developed bullying behaviors toward fellow co-workers and patients. Lally addresses the continuity of violence when she states:
Years of tolerance and indifference toward nurse-on-nurse violence on the part of the healthcare system and nurses themselves have led to the perpetuation of a cycle of violence passed from one generation of nurses to the next. (Lally 1). It is clear that the generational trending of violence being introduced to nursing students and new graduate nurses supports the continuity of violence within the healthcare setting, and also the early exit from the profession for many new graduate nurses. Affecting the longevity of new nurses in the industry are organizational issues, such as shift work, inefficient training, excessive stress, and lack of support from management. Many long term nurses within the environment may utilize bullying and not realize the action for what it is, or choosing a justifiable argument that the action falls under 'firm management.' Originally many studies have found the biggest perpetrators to be older nurses, who were apt to openly ridicule or verbally abuse new grads, further inhibiting progression their development during the first year. Trends are now shifting towards younger nurses being the biggest perpetrators, in part due to developing cynicism.
The importance of development and maturity in the first year of employment for the new nurse is further supported when McKenna, Smith, Poole and Coverdale state:
First year of practice is an important confidence-building phase for nurses and yet many new graduates are exposed to horizontal violence, which may negatively impact this process. (McKenna, Smith, Poole, Coverdale 7)
The first year of work for the new grad nurse is often the most challenging and stressful. The student turned professional is now responsible for multiple patients, and is expected to retain medical practices and facility policies quickly. This is the critical time period when the self-reflecting acceptance develops, leading to increased confidence and job satisfaction. The time and money spent on the average 6 month orientation is extensive, and the preceptor's decreased work performance due to involvement with the new nurse, causes increased duties, hours and expectations on other personnel. Further causing dissension in an environment where increased competence and requirements can cause stress even on experienced nursing staff. The effect of bullying is profound and may develop many different effects, such as frustration, anger, and isolation leading to decreased performance and productivity of patient care. Constant criticism and humiliation may develop low morale, leading to apprehension about going to work, causing increased sleeplessness, self doubt, and could ultimately lead to thoughts of self harm, substance abuse, and leaving the profession permanently. Ones career is not only tied to work but plays an important role in identity, self respect, and many times the nurse is not the only sufferer. The emotional turmoil that the family may experience can lead to relationship issues, and breakdown of the familial structure. The explanation provided by Laschinger, Grau, Finegan and Wilk supports causes for factors affecting career longevity:
Nurses who reported being bullied were more likely to have a negative perception of the organizational climate, lower job satisfaction, a higher propensity to leave their job, clinical levels of anxiety and depression and more sick days relative to nurses who did not report being bullied. (Laschinger. Grau, Finegan and Wilk 2)
Sick call offs due to bullying was 51% higher than those calling in sick for issues other than the effects of bullying. More severe events such as sexual harassment, lack of fellow employee support leading to patient harm, and rejection after being to told to apply for a promotion, has led to a small percentage of nurses leaving the profession completely after one event. Ultimately Cynicism and apprehension leading to increased absences or resignations is in part, due to burnout caused by bullying.
Barber states that the power to recognize and act upon bullying is a responsibility not utilized by managers as much as it should be: Bullying is always present somewhere; however, many people, including those who have the power and authority to prevent it, recognize or acknowledge it, are choosing not to see it. (Barber 3)
Over half of the victims have cited feeling unsafe reporting an incident, leading to a low incident reporting ratio, especially if the bully is the person the incident was to be reported to. Within the hierarchy of the work setting, new personnel have little power, and feeling a failure when asking for help from more experienced staff. It is suggested that behavior considered bullying in nature, may be considered more a practice in 'firm management.' in the eyes of the manager. Management boundaries ranging from the relaxed, easy going to consistent and fair and ending with the extreme of bullying may be perceived differently leading to a belief of being a bully and the manager not even being aware of it. Many institutions have anti-bullying policies but are not trained in the proper initiation of policy, and education of staff in acceptable behaviors as stated by Barber:
The latter is almost certain to exist in healthcare environments, where supervision and staff development can be poor, anti-bullying policies may be ignored, senior managers may 'turn a blind eye', and other employees could be too scared to speak out. (Barber 3)
When surveyed many new grads cited lack of support by a supervisor, high nurse to patient ratios and psychological exhaustion were prominent factors leading to burnout early in the profession.
Not only is the nursing workforce declining in the United States, but also worldwide. Around 2004 the average age of nurses was in the 40's, and presently a third of nurses are in their 50's. Many hopefuls sign up to enter nursing school, and sign up just to wait 2 years before getting placement into a program. While many hospital systems are recruiting nurses from other countries, such as the Philippines, numerous nurses move to other countries citing better pay opportunities and work environments.
As such the trend leaning toward increased lateral violence and heavy recruitment from other countries, is pushing health organizations to re-evaluate their recruitment strategies in order to retain a progressive workforce. Laschinger, Grau, Finegan and Wilk summarize the dilemma facing nursing in the United States: With more nurses eligible for retirement each year than those graduating from nursing education programmes, aggressive recruitment offers from foreign countries, and alarmingly high rates of turnover intentions,
ability of the nursing workforce to sustain itself is severely threatened. (Schlesinger, Gray, Finnegan and Will 2)
The indirect and direct costs of bullying is hard to estimate when evaluating effects high turnover rates, litigation costs, and lost work days, but it is substantial. There is no accurate way to analyze the cost of lost work based on bullying due to the inability to find support in documentation. This high cost added up with the costs of recruitment such as hiring bonuses and training can impact the number of nurses hired and environment practices they are hired into. To help decrease employee violence, many organizations are requiring employees to participate in training for the safe management of highly disruptive and aggressive patients offered by the Crisis Prevention Institute, in hopes to decrease violence on hospital staff. Other retention offers include employee incentive programs, attractive discounts from local stores, restaurants, auto, and phone companies. A factor outside the control of hospitals is bad publicity related to an injury or even worse, a death. The costs associated with this can be far reaching, such as medical claims, counseling, medical leaves of absence and other attendance concerns. The issue facing organizations is addressed by Chmieleski when he states:
The result of the trend toward increasing workplace violence, both externally from patients and visitors and internally with lateral violence (also called bullying), is an unprecedented human capital challenge that is forcing leaders in organizations to rethink how they attract, retain, and continuously develop a pool of talented workers. (Chmielewski 3)
The high level of stress from violence causing an unhealthy work environment leading to burnout for new graduates, is further adding to the nursing shortage in the healthcare industry. Leaders must become active in changing discriminatory beliefs to increase retention and longevity of new nurses, while decreasing burnout.
It is a general belief that one's actions are a reflection of their morals and beliefs, so logically if their beliefs are changed, then their actions will tend to follow. Development of laws and repercussions have helped to change negative behaviors and promote a change in behavior. Providing a knowledgeable and supportive atmosphere from school and the clinical atmosphere, will allow the new graduate to develop success in the clinical setting and prevent burnout due to the effects of bullying. Laschinger, Grau, Finegan and Wilk address the prevention of burnout by stating: These results suggest that future endeavors must be directed towards prevention of the initial stage of burnout, emotional exhaustion. This may be facilitated by ensuring access to workplace empowering structures, access to information, resources, support, opportunities to learn and grow, job discretion and strong working alliances in work settings. (Laschinger, Grau, Finegan and Wilk 9). Defining job roles and promoting goals for performance enhance higher productivity
within the team setting, along with a collaborative effort of all team members will aid in respect within the team setting. Collaborative behaviors such as showing trust, motivation to help on a project, and information exchange, will further promote appropriate behavior and reduce fears of retaliation and revenge against those who report negative behaviors. Skill development for leadership roles in addressing conflict, employee interaction and feedback, and providing further knowledge to the staff concerning the gravity of bullying. There are various actions that nurses can initiate on their own. Telling someone about being bullied is one of the most difficult and most important actions that can be taken. It promotes further knowledge concerning the incident and provide further understanding, and also helps to reduce feelings of loneliness and increase empowerment. Understanding the current legislation for harassment will help to evaluate the actions of the perpetrator. Keeping a log on incidences can show patterns and occurrences, and witnesses present at the time. Utilizing assertive communication to defend yourself. There are 3 areas to assertive communication, such as empathy, open ended questions, and buying time. Empathy helps one to understand the others view, allowing negotiations to happen involving two different viewpoints. Open ended questions puts the bully in the position to explain their actions, many times in front of others, and empowers the victim. Buying time allows the victim to cool off, while coming up with an effective statement or gain a witness. Many times this type of training is not in the curriculum of many nursing programs, as stated by McKenna, Smith, Poole and Coverdale: Primary prevention begins with education and training of staff; however, the majority of the respondents had no undergraduate and post-registration training to enable them to cope with adverse staff relationships. These concerns need to be considered in all areas of nursing including the clinical workplace, curriculum development of undergraduate programmes and development of first of practice orientation schemes supporting new graduates. (McKenna, Smith, Poole, Coverdale 6)
Providing strong policies against discrimination, bullying and harassment in the workplace will aid nurses in pursuing change within their work environments.
Continued review, implementation and employee participation at all levels from CNA's to senior directors, along with regulation policies in place for violations, will provide the framework of support. Nurses supported and encouraged by management to report or challenge bullying incidents will bring incidences into focus. Occupational health can play a supportive role in setting up further support for both victim and en actor in the form of support groups, therapy and family involvement. In recent years of study, bullying has created an increasing number of laws being pushed through legislation. The Equality Act was created to bring the various areas under one screen, organizing definitions, laws and acts. Some of the sections related to bullying include: Direct discrimination against an individual, engagement of indirect discrimination that disproportionately affects certain people and the acts are not justified, it is illegal to harass or bully another, and subjecting further harm after the act has been brought to the attention of others or acted upon. It is not clear yet what influence this act will have on bullying.
In an effort to send a prominent message concerning violence within the workplace, the ENA has become a strong force within the legal system in the development of laws, and must take much of the credit for the research and development of these laws, "The ENA has been a leader in the effort to advocate for legislative consequences for those who
commit an act of violence in the healthcare workplace." ( Chmielewski 4)
The laws may vary in different states, but over two thirds of the states had specific laws in place concerning violence against a healthcare worker. Through the advocacy of the ENA in the development of legal consequences for bullying, leadership figures will have more leverage when sending a clear directive that bullying will not be tolerated.
The prevalence of bullying is evident in the continuity seen through generations of nurses, with the younger generation carrying on from the older experienced nurses.
New graduate nurses are subjected increased criticism, humility and lack of support during the critical confidence building time of their first year of work. The degree of severity caused some nurses to leave the workforce after one incident. Many times the young nurse lacked the ability to bring the ill behaviors to their supervisors due to a lack of acknowledgment, action by, or the fact that the perpetrator was the supervisor. Numerous health issues develop such as anxiety, depression, increasing to extremes such as suicide. Many institutions have policies in place, but do not enforce them due to inefficient supervisors or lack of institution education in prevention, which in part led to employee fear of retribution if they complained. Skills and knowledge such as assertive communication, employee support and promotion of a team atmosphere can help promote health, pride and happiness in the house of healing.
