AN INDEPENDENT VOICE FOR NURSING
bs_bs_banner
Antibullying Workshops: Shaping Minority Nursing Leaders Through Curriculum Innovation Aida L. Egues, DNP, RN, APHN-BC, CNE, and Elaine Z. Leinung, DNP, RN, FNP-BC, CNE Aida L. Egues, DNP, RN, APHN-BC, CNE, is Assistant Professor, Department of Nursing, New York City College of Technology of The City University of New York, Brooklyn, NY; and Elaine Z. Leinung, DNP, RN, FNP-BC, CNE, is Assistant Professor, Department of Nursing, New York City College of Technology of The City University of New York, Brooklyn, NY. Keywords Education, innovation, interprofessional education, leadership, professional issue Correspondence Aida L. Egues, DNP, RN, APHN-BC, CNE, Department of Nursing, New York City College of Technology of The City University of New York, Brooklyn, NY E-mail: [email protected] The workshops mentioned in the article received Institutional Review Board for Protection of Human Subjects approval. Author’s Note: The article addresses content from a peer-reviewed concurrent podium session selected for presentation at the National Association of Hispanic Nurses (NAHN) 37th Annual Conference (2012), Healthcare Reform: Mentoring the Next Generation of Nursing Leaders, and within Nursing Forum (2013), doi:10.1111/nuf.12028.
Egues
Leinung
PROBLEM. Bullying is a phenomenon that threatens nurse recruitment and retention. As such, nurse educators should be called upon to innovatively create ethical and safe informative and practice spaces for the development and socialization of future practicing nurses. Creation of such spaces would be especially important for learners of minority background needed to help care for our nation’s growing populations. METHOD. A variety of theory-driven strategies were employed to construct innovative workshops as part of teaching methodology for undergraduate nursing curriculum at a designated Hispanic- and minorityserving college. Nursing faculty provided the workshops in concert with mentored nursing student scholars who were likewise interested in bullying cessation. FINDINGS. Surveys from 230 nursing student participants in workshops revealed a 10–33% increase in self-reported identification of various facets of the bullying phenomenon. Students’ narrative reflections revealed personal experiences with bullying, a raised awareness of its phenomenon, and an improved dedication to ending bullying. CONCLUSIONS. Nurse educators can help influence antibullying awareness through workshops integrated into their program of study. This innovative curriculum strategy demonstrates nurse educator commitment to antibullying that is focused on guiding and promoting the advocacy of educational, leadership, and professional opportunities and skills growth for minority nursing student scholars.
In the United States, between 17% and 76% of registered nurses (RNs) have been bullied at work (Vessey, DeMarco, Gaffney, & Budin, 2009). Workplace bullying leads to RN absenteeism, anxiety, emotional distress, job termination, low morale, posttraumatic stress disorder, and psychosomatic illness (Dellasega, 2011; Stokowski, 2011). Bullying among nurses has personal and professional consequences, as well as workforce implications. The negative effects of bullying force RNs to leave clinical practice (MacKusick & Minick, 2010), affecting recruitment and retention. Nurse educators must learn what bullying constitutes within the environments of nursing student learners.
240 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
A. L. Egues and E. Z. Leinung Bullying Defined Bullying creates harmful, hostile work environments (Cleary, Hunt, & Horsfall, 2010; Luparell, 2011) that curtail the ability of victims to cope (Hansen, Hogh, & Persson, 2011). Horizontal or lateral bullying—also known as horizontal or lateral violence—describes peer-to-peer overt or subtle aggression among colleagues at the same level (Longo, 2010). Bullying behaviors include use of abusive, degrading, gossiping, or threatening language; displaying favoritism; ignoring attempts at communication; publicly humiliating or purposefully excluding someone; sending aggressively curt or inappropriate e-mail messages; and refusing to help or mentor a targeted victim (Capitulo, 2009). With vertical or hierarchical violence, an administrative bully uses status to control or demean employees through biased work assignments, inaccurate evaluations, and sabotage of advancement or promotion (Cleary et al., 2010). The imbalance of power in such situations makes any defense against a bully difficult. Unfortunately, power situations that fuel bully behavior exist across all levels of nursing education. For example, nursing students in clinical placement settings have reported experiencing or witnessing abuse by and from RNs (Hinchberger, 2009). Nursing students have also reported being bullied primarily by classmates and secondarily by nursing faculty (Celik & Bayraktar, 2004). However, nursing faculty members have felt bullied by nursing students (Luparell, 2007) through acts of physical and verbal aggression, and unfair evaluations (Kolanko et al., 2006). And yet nursing faculty members have bullied program directors (Mintz-Binder & Calkins, 2012). To help curtail such widespread bullying behavior, nurse educators must learn why bullying exists before beginning its discussion. Reasons for Bullying The concepts of power and power imbalances appear in the literature as the foundations of bullying behavior (Baltimore, 2006; Gillen, Sinclair, & Kernohan, 2004). Power imbalance in nursing is owed to marginalizing behavior more likely perpetuated against women (Hinchberger, 2009), an employer lack of intervention against bullying (Duffy, 2009), and a significantly higher prevalence rate of bullying against minority individuals (Hoel, Giga, & Davidson, 2007). Hence, nursing students of minority background may perceive greater lack of control over the workplace by
Antibullying Workshops other dominant and more powerful groups, may feel unsupported, and may have trouble finding mentors for guidance. It is therefore especially critical to try to understand how to improve and sustain a culture that will foster minority nursing students’ further education, recruitment, and retention (Egues, 2010). Nurse educators should focus on addressing the negative culture of bullying as an essential part of student learner development and socialization. Shaping future nursing leaders depends on establishing and supporting education and practice spaces that student learners feel are ethical and safe. To build such spaces, engaging in and promoting student learning opportunities that focus on addressing the cessation of bullying must be included as part of teaching methodology in nursing curricula to help develop and empower future nursing leaders as positive change agents. Conceptual Framework There is little research into tackling any aspect of bullying specifically through nursing education as part of curriculum innovation and practice. There is even less discussion about bullying experienced by individuals of minority background. This article describes a teaching methodology initiative derived from the literature, and based upon the authors’ personal and professional experiences with bullying behavior in nursing. The authors felt dedicated to addressing bullying as an important social issue that potentially hampers minority nursing student progression and retention. Therefore, workshops conceived and led by the authors were based upon theoretical frameworks of mentoring (Benner, 2001) as well as of personal and organizational empowerment (Kanter, 1993). The aim of the workshops was to help guide and promote the advocacy of educational, leadership, and professional opportunities and skills growth for the next generation of minority nurses committed to putting an end to the bullying phenomenon. Method Multiple workshops were provided to nursing students (n = 230) at a college designated by the U.S. Department of Education as both a Hispanic-serving institution and a minority-serving institution within a multicultural, urban environment. Hence, as the authors strongly felt that a sense of powerlessness serves little purpose in nursing education, workshops 241
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Antibullying Workshops
A. L. Egues and E. Z. Leinung
Figure 1. Pretest/Posttest Averaged Results by Question
were created to facilitate that nursing student learners (a) recognize covert and overt signs of bullying; (b) practice techniques of empowerment through appropriate communication and behavior; and (c) learn negotiation of political landscapes regardless of practice level and specialty. The 2-hr workshops were first conducted as part of teaching methodology in the last clinical course in the undergraduate nursing program, and then promoted and extended for the benefit of all nursing students enrolled with Institutional Review Board approval granted. Workshops as Process A variety of author-led strategies based upon highimpact educational practices (Kuh, 2008) were employed in the workshops to engage nursing students’ affective, cognitive, and psychomotor domains of learning. For example, the authors’ written case studies on bullying were used as part of collaborative group work to allow students to tease out and develop definitions of bullying, examples and types of bullying, and suggested interventions. Spontaneous and humorous role-playing activities allowed students to act out either perceived or real incidents of peer-on-peer bullying at school, nurseon-nurse bullying within a hospital and community setting, and student-on-professor bullying. The authors posted to overhead slides any ethical lessons learned from personal and student experiences of bullying. Shared faculty and student feedback led to communication strategies on how to address a bully. Bullying statistics and bullying theories were addressed. Students 242 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
were provided with small bursts of reflection time and journaling for introspection as to perpetrator, victim, or bystander roles that they may have played in bullying. A goal of the workshop was to reinforce that a pervasive bullying culture supports barriers to effective, safe, and quality health care. Therefore, antibullying policybuilding recommendations and self-care activities provided by students, faculty, and the literature were displayed on paper charts around the room. In further support of leadership initiatives, four nursing students mentored by the authors were chosen to take a collaboratively active part in the workshops. These students expressed a keen interest in antibullying and so engaged in undergraduate research on the bullying phenomenon. The students participated with their faculty mentors in all aspects of the workshops and additionally prepared two research posters for presentation at the college’s undergraduate scholars event. This high-impact education practice of participation in undergraduate research further enriched student experience and exposure. Pretesting and posttesting and narratives of nursing students who participated in multiple workshops during three semesters have been analyzed to identify experiences of bullying. Pretest and posttest survey statements are included as an appendix. Figure 1 shows a 10–33% increase in self-reported recognition of the many facets of the bullying phenomenon. Workshop participants reported the largest increases in knowing someone engaged in horizontal violence in school as well as in the clinical setting. In terms of personal involvement in bullying, participants
A. L. Egues and E. Z. Leinung acknowledged having engaged in horizontal violence more so at school than in the clinical setting. Interestingly, posttests reflected increased self-reported recognition of personal involvement in bullying at both the school and the clinical settings. Workshop Reflections Students’ reflections revealed personal experiences with bullying, a raised awareness of the bullying phenomenon, and an improved dedication to ending bullying with an ownership of leading advocacy in creating culturally competent, ethical, and positive work environments. The authors have chosen examples of workshop participant reflections. Some examples that address personal experiences with bullying include the following: “The nurses make faces when they see us coming to clinical.” “I often feel that as a minority female, I’m supposed to just accept and expect comments (that) I’m not smart enough to do well in class or clinical to become a nurse.” “It upsets me when professors don’t seem to care by the comments they make. It makes me want to drop out of the program.” “I have asked myself over and over the same questions. What am I doing here? Should I even keep trying to be a nurse? I just see and feel disrespected. I don’t get it.” Reflections also addressed insight as to participants’ raised awareness of the bullying phenomenon. As examples: “I did not realize that a ‘bystander’ was part of the problem.” “I thought the awful way we treat each other was part of nursing school.” “I now know how to speak up and say that I don’t deserve to be bullied.” Workshop participants also indicated an improved dedication to ending bullying while serving as advocates in creating bully-free work zones. Comments demonstrating increases in antibullying selfawareness at personal and professional levels follow:
Antibullying Workshops “If I’m not out there to care for those like my family, then who will? I have to make sure we all stand up, speak up, and take care of one another. I shouldn’t be mean to be a nurse.” “This was very enlightening—I mean things won’t change overnight, but at least we know why it happens and have some tools for self-defense!” “So, if we don’t bring about positive change in the profession, we will be losing minority nurses and there will be nobody in these workshops.” Positive workshop outcomes have led to requests for presentation by other departments within the school of health professions in the college as part of high-impact teaching methodology within courses that employ having a guest speaker during lecture sessions. Hospitalbased and for-profit and nonprofit agencies within the community have requested similar workshops for their own multicultural, multidisciplinary staff. Recommendations for Nurse Educators Nursing educators need to recognize that successful integration of teaching methodology that addresses potentially divisive issues such as bullying is essential for the preparation of minority nursing students as future practitioners. Workplace bullying leads to decreased recruitment and retention, and may negatively affect the way nurses interact with their clients and with each other. Nurse educators should then make efforts early in nursing education to teach about bullying so future nurses do not perpetuate the behavior in both the school and workplace settings. As students and as nurse educators, the authors have been addressing antibullying for almost two decades. For nursing faculty interested in curtailing bullying, the authors recommend gaining an understanding about the phenomenon by attending peer-reviewed conference seminars and training sessions that provide continuing education credit and/or certificates of attendance. In particular, seminars and training sessions focused on anti-bullying should address but not be limited to the following topics: (a) conflict management and conflict resolution, (b) dealing with difficult people, (c) communication and listening skills enhancement, (d) the art of negotiation, and (e) dealing with stress management. When instability exists in the educational workplace, the authors recommend that nursing faculty manage their own classroom and clinical settings by helping set formal 243
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Antibullying Workshops mentoring relationships, informal and fun activities or committees, and keep a mutually respectful open-door policy for faculty and students. Nurse educators who advocate for workshops against bullying need to know that doing so involves several actions: (a) reflecting upon contemporary and high-impact educational and practice competencies demanded of faculty and students; (b) properly gathering and employing timely evidence-based, pragmatic, and theoretically based information; (c) engaging in beneficial communication; (d) getting employer commitment; and (e) working toward policy implementation and follow-up (Egues & Leinung, 2013). Additionally, regular self-inventory should take place: learning how to properly channel anger, how to step back, and writing notes to self on the difference between a manager who leads versus a manager who bullies are all important. All of these actions are critical in teaching nursing students how to simply “be nice.” Having workshops for nursing students is a creative way of teaching how to deal with bullying; it is particularly salient for those minority students who may feel lack of power within their school and/or work environments. For nursing student scholars, offering them the opportunity at research and its implementation further shapes minority leaders through curriculum innovation. Conclusion Nursing faculty who are dedicated to positively shaping the present and future nursing environments of minority nursing students must role model care of the entire self as part of balanced personal and professional growth. For students who may face challenges of empowerment, it is especially critical to create safe informative and practice settings free of abuse and intimidation, particularly for those nursing students who may be too apprehensive or reserved to champion for safe spaces. It is incumbent upon nurse educators to consider how contemporary issues impact the recruitment and retention of future nursing leaders who will best care for our populations of minority background. To that end, the authors’ workshops on bullying were innovatively designed to help nurse educators to influence minority nursing students in becoming confident individuals empowered to stop harm from hampering their personal and professional growth in the name of helping all others.
244 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
A. L. Egues and E. Z. Leinung References Baltimore, J. J. (2006). Nurse collegiality: Fact or fiction. Nursing Management, 37(5), 28–36. Benner, P. (2001). From novice to expert. Excellence and power in clinical nursing practice. Commemorative edition. Upper Saddle River, NJ: Prentice-Hall, Inc. Capitulo, K. L. (2009). Addressing disruptive behavior by implementing a code of professionalism to transform hospital culture. Nurse Leader, 7(2), 38–43. Celik, S. S., & Bayraktar, N. (2004). A study of nursing student abuse in Turkey. Journal of Nursing Education, 43(7), 330–336. Cleary, M., Hunt, G. E., & Horsfall, J. (2010). Identifying and addressing bullying in nursing. Issues in Mental Health Nursing, 31, 331–335. Dellasega, C. (2011). When nurses hurt nurses. Recognizing and overcoming the cycle of nurse bullying. Indianapolis, IN: Sigma Theta Tau International. Duffy, M. (2009). Preventing workplace mobbing and bullying with effective organizational consultation, policies and legislation. Consulting Psychology Journal: Practice and Research, 61(3), 242–262. Egues, A. (2010). The relationship between mentoring and level of practice among Hispanic RNs. International Journal of Environmental, Cultural, Economic and Social Sustainability, 6(2), 293–304. Egues, A. L., & Leinung, E. Z. (2013). The bully within and without: Strategies to address horizontal violence in nursing. Nursing Forum, 48(3), 185–190. doi:10.1111/ nuf.12028 Gillen, P., Sinclair, M., & Kernohan, G. (2004). A concept analysis of bullying in midwifery. Evidence-Based Midwifery, 2(2), 46–51. Hansen, A. M., Hogh, A., & Persson, R. (2011). Frequency of bullying at work, physiological response, and mental health. Journal of Psychosomatic Research, 70, 19–27. Hinchberger, P. A. (2009). Violence against female student nurses in the workplace. Nursing Forum, 44(1), 37– 46. Hoel, H., Giga, S. I., & Davidson, M. J. (2007). Expectations and realities of student nurses’ experiences of negative behaviour and bullying in clinical placement and the influences of socialisation processes. Health Services Management Research, 20(4), 270–278. Kanter, R. M. (1993). Men and women of the corporation (2nd ed.). New York: Basic Books. Kolanko, K. M., Clark, C., Heinrich, K. T., Olive, D., Serembus, J. F., & Sifford, K. S. (2006). Academic dishonesty, bullying, incivility, and violence: Difficult challenges facing nurse educators. Nursing Education Perspectives, 27(1), 34–43. Kuh, G. D. (2008). High-impact educational practices: What they are, who has access to them, and why they matter. Washington, DC: LEAP Publications of the Association of American Colleges and Universities. Longo, J. (2010). Combating disruptive behaviors: Strategies to promote a healthy work environment. Online Journal of Issues in Nursing, 15(1), Manuscript 5. doi:10.3912/OJIN .Vol15No01Man05
Antibullying Workshops
A. L. Egues and E. Z. Leinung
Stokowski, L. A. (2011). A matter of respect and dignity: Bullying in the nursing profession: How common is bullying in nursing? Retrieved from http://www.medscape .com/viewarticle/729474 Vessey, J. A., DeMarco, R. F., Gaffney, D., & Budin, W. C. (2009). Bullying of staff nurses in the workplace: A preliminary study for developing personal or organizational strategies for the transformation of hostile to healthy workplace environments. Journal of Professional Nursing, 25, 299–306.
Luparell, S. (2007). The effects of student incivility on nursing faculty. Journal of Nursing Education, 46(1), 15–19. Luparell, S. (2011). Incivility in nursing: The connection between academia and clinical settings. Critical Care Nurse, 31, 92–95. MacKusick, C. I., & Minick, P. (2010). Why are nurses leaving? Findings from an initial qualitative study on nursing attrition. Medsurg Nursing, 19, 335–340. Mintz-Binder, R. D., & Calkins, R. D. (2012). Exposure to bullying at the associate degree nursing program director level. Teaching and Learning in Nursing, 7, 152–158.
Appendix Horizontal/Lateral Violence Workshop Pretest and Posttest Please provide answers to the following statements. Put a circle around the response that you feel best reflects your experience. 1. I hear about horizontal/lateral violence happening in school. Never 1
Seldom/Rarely 2
Sometimes 3
Often 4
Always 5
Often 4
Always 5
Often 4
Always 5
Often 4
Always 5
2. I hear about horizontal/lateral violence happening in the clinical setting. Never 1
Seldom/Rarely 2
Sometimes 3
3. I have been a victim of horizontal/lateral violence at school. Never 1
Seldom/Rarely 2
Sometimes 3
4. I have been a victim of horizontal/violence in the clinical setting. Never 1
Seldom/Rarely 2
Sometimes 3
5. I have known individuals who have engaged in horizontal/lateral violence at school. Never 1
Seldom/Rarely 2
Sometimes 3
Often 4
Always 5
6. I have known individuals who have engaged in horizontal/lateral violence in the clinical setting. Never 1
Seldom/Rarely 2
Sometimes 3
Often 4
Always 5
Often 4
Always 5
Often 4
Always 5
7. I have engaged in horizontal/lateral violence at school. Never 1
Seldom/Rarely 2
Sometimes 3
8. I have engaged in horizontal/lateral violence in the clinical setting. Never 1
Seldom/Rarely 2
Sometimes 3
245 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Antibullying Workshops
A. L. Egues and E. Z. Leinung
Please write your answer to the following questions: 1. How would you describe horizontal/lateral violence, and how does it make you feel? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________ 2. Can you describe an example of horizontal/lateral violence that you have seen or experienced and how you dealt with it? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ____________ Thank you for your time and consideration!
246 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
bs_bs_banner
Antibullying Workshops: Shaping Minority Nursing Leaders Through Curriculum Innovation Aida L. Egues, DNP, RN, APHN-BC, CNE, and Elaine Z. Leinung, DNP, RN, FNP-BC, CNE Aida L. Egues, DNP, RN, APHN-BC, CNE, is Assistant Professor, Department of Nursing, New York City College of Technology of The City University of New York, Brooklyn, NY; and Elaine Z. Leinung, DNP, RN, FNP-BC, CNE, is Assistant Professor, Department of Nursing, New York City College of Technology of The City University of New York, Brooklyn, NY. Keywords Education, innovation, interprofessional education, leadership, professional issue Correspondence Aida L. Egues, DNP, RN, APHN-BC, CNE, Department of Nursing, New York City College of Technology of The City University of New York, Brooklyn, NY E-mail: [email protected] The workshops mentioned in the article received Institutional Review Board for Protection of Human Subjects approval. Author’s Note: The article addresses content from a peer-reviewed concurrent podium session selected for presentation at the National Association of Hispanic Nurses (NAHN) 37th Annual Conference (2012), Healthcare Reform: Mentoring the Next Generation of Nursing Leaders, and within Nursing Forum (2013), doi:10.1111/nuf.12028.
Egues
Leinung
PROBLEM. Bullying is a phenomenon that threatens nurse recruitment and retention. As such, nurse educators should be called upon to innovatively create ethical and safe informative and practice spaces for the development and socialization of future practicing nurses. Creation of such spaces would be especially important for learners of minority background needed to help care for our nation’s growing populations. METHOD. A variety of theory-driven strategies were employed to construct innovative workshops as part of teaching methodology for undergraduate nursing curriculum at a designated Hispanic- and minorityserving college. Nursing faculty provided the workshops in concert with mentored nursing student scholars who were likewise interested in bullying cessation. FINDINGS. Surveys from 230 nursing student participants in workshops revealed a 10–33% increase in self-reported identification of various facets of the bullying phenomenon. Students’ narrative reflections revealed personal experiences with bullying, a raised awareness of its phenomenon, and an improved dedication to ending bullying. CONCLUSIONS. Nurse educators can help influence antibullying awareness through workshops integrated into their program of study. This innovative curriculum strategy demonstrates nurse educator commitment to antibullying that is focused on guiding and promoting the advocacy of educational, leadership, and professional opportunities and skills growth for minority nursing student scholars.
In the United States, between 17% and 76% of registered nurses (RNs) have been bullied at work (Vessey, DeMarco, Gaffney, & Budin, 2009). Workplace bullying leads to RN absenteeism, anxiety, emotional distress, job termination, low morale, posttraumatic stress disorder, and psychosomatic illness (Dellasega, 2011; Stokowski, 2011). Bullying among nurses has personal and professional consequences, as well as workforce implications. The negative effects of bullying force RNs to leave clinical practice (MacKusick & Minick, 2010), affecting recruitment and retention. Nurse educators must learn what bullying constitutes within the environments of nursing student learners.
240 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
A. L. Egues and E. Z. Leinung Bullying Defined Bullying creates harmful, hostile work environments (Cleary, Hunt, & Horsfall, 2010; Luparell, 2011) that curtail the ability of victims to cope (Hansen, Hogh, & Persson, 2011). Horizontal or lateral bullying—also known as horizontal or lateral violence—describes peer-to-peer overt or subtle aggression among colleagues at the same level (Longo, 2010). Bullying behaviors include use of abusive, degrading, gossiping, or threatening language; displaying favoritism; ignoring attempts at communication; publicly humiliating or purposefully excluding someone; sending aggressively curt or inappropriate e-mail messages; and refusing to help or mentor a targeted victim (Capitulo, 2009). With vertical or hierarchical violence, an administrative bully uses status to control or demean employees through biased work assignments, inaccurate evaluations, and sabotage of advancement or promotion (Cleary et al., 2010). The imbalance of power in such situations makes any defense against a bully difficult. Unfortunately, power situations that fuel bully behavior exist across all levels of nursing education. For example, nursing students in clinical placement settings have reported experiencing or witnessing abuse by and from RNs (Hinchberger, 2009). Nursing students have also reported being bullied primarily by classmates and secondarily by nursing faculty (Celik & Bayraktar, 2004). However, nursing faculty members have felt bullied by nursing students (Luparell, 2007) through acts of physical and verbal aggression, and unfair evaluations (Kolanko et al., 2006). And yet nursing faculty members have bullied program directors (Mintz-Binder & Calkins, 2012). To help curtail such widespread bullying behavior, nurse educators must learn why bullying exists before beginning its discussion. Reasons for Bullying The concepts of power and power imbalances appear in the literature as the foundations of bullying behavior (Baltimore, 2006; Gillen, Sinclair, & Kernohan, 2004). Power imbalance in nursing is owed to marginalizing behavior more likely perpetuated against women (Hinchberger, 2009), an employer lack of intervention against bullying (Duffy, 2009), and a significantly higher prevalence rate of bullying against minority individuals (Hoel, Giga, & Davidson, 2007). Hence, nursing students of minority background may perceive greater lack of control over the workplace by
Antibullying Workshops other dominant and more powerful groups, may feel unsupported, and may have trouble finding mentors for guidance. It is therefore especially critical to try to understand how to improve and sustain a culture that will foster minority nursing students’ further education, recruitment, and retention (Egues, 2010). Nurse educators should focus on addressing the negative culture of bullying as an essential part of student learner development and socialization. Shaping future nursing leaders depends on establishing and supporting education and practice spaces that student learners feel are ethical and safe. To build such spaces, engaging in and promoting student learning opportunities that focus on addressing the cessation of bullying must be included as part of teaching methodology in nursing curricula to help develop and empower future nursing leaders as positive change agents. Conceptual Framework There is little research into tackling any aspect of bullying specifically through nursing education as part of curriculum innovation and practice. There is even less discussion about bullying experienced by individuals of minority background. This article describes a teaching methodology initiative derived from the literature, and based upon the authors’ personal and professional experiences with bullying behavior in nursing. The authors felt dedicated to addressing bullying as an important social issue that potentially hampers minority nursing student progression and retention. Therefore, workshops conceived and led by the authors were based upon theoretical frameworks of mentoring (Benner, 2001) as well as of personal and organizational empowerment (Kanter, 1993). The aim of the workshops was to help guide and promote the advocacy of educational, leadership, and professional opportunities and skills growth for the next generation of minority nurses committed to putting an end to the bullying phenomenon. Method Multiple workshops were provided to nursing students (n = 230) at a college designated by the U.S. Department of Education as both a Hispanic-serving institution and a minority-serving institution within a multicultural, urban environment. Hence, as the authors strongly felt that a sense of powerlessness serves little purpose in nursing education, workshops 241
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Antibullying Workshops
A. L. Egues and E. Z. Leinung
Figure 1. Pretest/Posttest Averaged Results by Question
were created to facilitate that nursing student learners (a) recognize covert and overt signs of bullying; (b) practice techniques of empowerment through appropriate communication and behavior; and (c) learn negotiation of political landscapes regardless of practice level and specialty. The 2-hr workshops were first conducted as part of teaching methodology in the last clinical course in the undergraduate nursing program, and then promoted and extended for the benefit of all nursing students enrolled with Institutional Review Board approval granted. Workshops as Process A variety of author-led strategies based upon highimpact educational practices (Kuh, 2008) were employed in the workshops to engage nursing students’ affective, cognitive, and psychomotor domains of learning. For example, the authors’ written case studies on bullying were used as part of collaborative group work to allow students to tease out and develop definitions of bullying, examples and types of bullying, and suggested interventions. Spontaneous and humorous role-playing activities allowed students to act out either perceived or real incidents of peer-on-peer bullying at school, nurseon-nurse bullying within a hospital and community setting, and student-on-professor bullying. The authors posted to overhead slides any ethical lessons learned from personal and student experiences of bullying. Shared faculty and student feedback led to communication strategies on how to address a bully. Bullying statistics and bullying theories were addressed. Students 242 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
were provided with small bursts of reflection time and journaling for introspection as to perpetrator, victim, or bystander roles that they may have played in bullying. A goal of the workshop was to reinforce that a pervasive bullying culture supports barriers to effective, safe, and quality health care. Therefore, antibullying policybuilding recommendations and self-care activities provided by students, faculty, and the literature were displayed on paper charts around the room. In further support of leadership initiatives, four nursing students mentored by the authors were chosen to take a collaboratively active part in the workshops. These students expressed a keen interest in antibullying and so engaged in undergraduate research on the bullying phenomenon. The students participated with their faculty mentors in all aspects of the workshops and additionally prepared two research posters for presentation at the college’s undergraduate scholars event. This high-impact education practice of participation in undergraduate research further enriched student experience and exposure. Pretesting and posttesting and narratives of nursing students who participated in multiple workshops during three semesters have been analyzed to identify experiences of bullying. Pretest and posttest survey statements are included as an appendix. Figure 1 shows a 10–33% increase in self-reported recognition of the many facets of the bullying phenomenon. Workshop participants reported the largest increases in knowing someone engaged in horizontal violence in school as well as in the clinical setting. In terms of personal involvement in bullying, participants
A. L. Egues and E. Z. Leinung acknowledged having engaged in horizontal violence more so at school than in the clinical setting. Interestingly, posttests reflected increased self-reported recognition of personal involvement in bullying at both the school and the clinical settings. Workshop Reflections Students’ reflections revealed personal experiences with bullying, a raised awareness of the bullying phenomenon, and an improved dedication to ending bullying with an ownership of leading advocacy in creating culturally competent, ethical, and positive work environments. The authors have chosen examples of workshop participant reflections. Some examples that address personal experiences with bullying include the following: “The nurses make faces when they see us coming to clinical.” “I often feel that as a minority female, I’m supposed to just accept and expect comments (that) I’m not smart enough to do well in class or clinical to become a nurse.” “It upsets me when professors don’t seem to care by the comments they make. It makes me want to drop out of the program.” “I have asked myself over and over the same questions. What am I doing here? Should I even keep trying to be a nurse? I just see and feel disrespected. I don’t get it.” Reflections also addressed insight as to participants’ raised awareness of the bullying phenomenon. As examples: “I did not realize that a ‘bystander’ was part of the problem.” “I thought the awful way we treat each other was part of nursing school.” “I now know how to speak up and say that I don’t deserve to be bullied.” Workshop participants also indicated an improved dedication to ending bullying while serving as advocates in creating bully-free work zones. Comments demonstrating increases in antibullying selfawareness at personal and professional levels follow:
Antibullying Workshops “If I’m not out there to care for those like my family, then who will? I have to make sure we all stand up, speak up, and take care of one another. I shouldn’t be mean to be a nurse.” “This was very enlightening—I mean things won’t change overnight, but at least we know why it happens and have some tools for self-defense!” “So, if we don’t bring about positive change in the profession, we will be losing minority nurses and there will be nobody in these workshops.” Positive workshop outcomes have led to requests for presentation by other departments within the school of health professions in the college as part of high-impact teaching methodology within courses that employ having a guest speaker during lecture sessions. Hospitalbased and for-profit and nonprofit agencies within the community have requested similar workshops for their own multicultural, multidisciplinary staff. Recommendations for Nurse Educators Nursing educators need to recognize that successful integration of teaching methodology that addresses potentially divisive issues such as bullying is essential for the preparation of minority nursing students as future practitioners. Workplace bullying leads to decreased recruitment and retention, and may negatively affect the way nurses interact with their clients and with each other. Nurse educators should then make efforts early in nursing education to teach about bullying so future nurses do not perpetuate the behavior in both the school and workplace settings. As students and as nurse educators, the authors have been addressing antibullying for almost two decades. For nursing faculty interested in curtailing bullying, the authors recommend gaining an understanding about the phenomenon by attending peer-reviewed conference seminars and training sessions that provide continuing education credit and/or certificates of attendance. In particular, seminars and training sessions focused on anti-bullying should address but not be limited to the following topics: (a) conflict management and conflict resolution, (b) dealing with difficult people, (c) communication and listening skills enhancement, (d) the art of negotiation, and (e) dealing with stress management. When instability exists in the educational workplace, the authors recommend that nursing faculty manage their own classroom and clinical settings by helping set formal 243
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Antibullying Workshops mentoring relationships, informal and fun activities or committees, and keep a mutually respectful open-door policy for faculty and students. Nurse educators who advocate for workshops against bullying need to know that doing so involves several actions: (a) reflecting upon contemporary and high-impact educational and practice competencies demanded of faculty and students; (b) properly gathering and employing timely evidence-based, pragmatic, and theoretically based information; (c) engaging in beneficial communication; (d) getting employer commitment; and (e) working toward policy implementation and follow-up (Egues & Leinung, 2013). Additionally, regular self-inventory should take place: learning how to properly channel anger, how to step back, and writing notes to self on the difference between a manager who leads versus a manager who bullies are all important. All of these actions are critical in teaching nursing students how to simply “be nice.” Having workshops for nursing students is a creative way of teaching how to deal with bullying; it is particularly salient for those minority students who may feel lack of power within their school and/or work environments. For nursing student scholars, offering them the opportunity at research and its implementation further shapes minority leaders through curriculum innovation. Conclusion Nursing faculty who are dedicated to positively shaping the present and future nursing environments of minority nursing students must role model care of the entire self as part of balanced personal and professional growth. For students who may face challenges of empowerment, it is especially critical to create safe informative and practice settings free of abuse and intimidation, particularly for those nursing students who may be too apprehensive or reserved to champion for safe spaces. It is incumbent upon nurse educators to consider how contemporary issues impact the recruitment and retention of future nursing leaders who will best care for our populations of minority background. To that end, the authors’ workshops on bullying were innovatively designed to help nurse educators to influence minority nursing students in becoming confident individuals empowered to stop harm from hampering their personal and professional growth in the name of helping all others.
244 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
A. L. Egues and E. Z. Leinung References Baltimore, J. J. (2006). Nurse collegiality: Fact or fiction. Nursing Management, 37(5), 28–36. Benner, P. (2001). From novice to expert. Excellence and power in clinical nursing practice. Commemorative edition. Upper Saddle River, NJ: Prentice-Hall, Inc. Capitulo, K. L. (2009). Addressing disruptive behavior by implementing a code of professionalism to transform hospital culture. Nurse Leader, 7(2), 38–43. Celik, S. S., & Bayraktar, N. (2004). A study of nursing student abuse in Turkey. Journal of Nursing Education, 43(7), 330–336. Cleary, M., Hunt, G. E., & Horsfall, J. (2010). Identifying and addressing bullying in nursing. Issues in Mental Health Nursing, 31, 331–335. Dellasega, C. (2011). When nurses hurt nurses. Recognizing and overcoming the cycle of nurse bullying. Indianapolis, IN: Sigma Theta Tau International. Duffy, M. (2009). Preventing workplace mobbing and bullying with effective organizational consultation, policies and legislation. Consulting Psychology Journal: Practice and Research, 61(3), 242–262. Egues, A. (2010). The relationship between mentoring and level of practice among Hispanic RNs. International Journal of Environmental, Cultural, Economic and Social Sustainability, 6(2), 293–304. Egues, A. L., & Leinung, E. Z. (2013). The bully within and without: Strategies to address horizontal violence in nursing. Nursing Forum, 48(3), 185–190. doi:10.1111/ nuf.12028 Gillen, P., Sinclair, M., & Kernohan, G. (2004). A concept analysis of bullying in midwifery. Evidence-Based Midwifery, 2(2), 46–51. Hansen, A. M., Hogh, A., & Persson, R. (2011). Frequency of bullying at work, physiological response, and mental health. Journal of Psychosomatic Research, 70, 19–27. Hinchberger, P. A. (2009). Violence against female student nurses in the workplace. Nursing Forum, 44(1), 37– 46. Hoel, H., Giga, S. I., & Davidson, M. J. (2007). Expectations and realities of student nurses’ experiences of negative behaviour and bullying in clinical placement and the influences of socialisation processes. Health Services Management Research, 20(4), 270–278. Kanter, R. M. (1993). Men and women of the corporation (2nd ed.). New York: Basic Books. Kolanko, K. M., Clark, C., Heinrich, K. T., Olive, D., Serembus, J. F., & Sifford, K. S. (2006). Academic dishonesty, bullying, incivility, and violence: Difficult challenges facing nurse educators. Nursing Education Perspectives, 27(1), 34–43. Kuh, G. D. (2008). High-impact educational practices: What they are, who has access to them, and why they matter. Washington, DC: LEAP Publications of the Association of American Colleges and Universities. Longo, J. (2010). Combating disruptive behaviors: Strategies to promote a healthy work environment. Online Journal of Issues in Nursing, 15(1), Manuscript 5. doi:10.3912/OJIN .Vol15No01Man05
Antibullying Workshops
A. L. Egues and E. Z. Leinung
Stokowski, L. A. (2011). A matter of respect and dignity: Bullying in the nursing profession: How common is bullying in nursing? Retrieved from http://www.medscape .com/viewarticle/729474 Vessey, J. A., DeMarco, R. F., Gaffney, D., & Budin, W. C. (2009). Bullying of staff nurses in the workplace: A preliminary study for developing personal or organizational strategies for the transformation of hostile to healthy workplace environments. Journal of Professional Nursing, 25, 299–306.
Luparell, S. (2007). The effects of student incivility on nursing faculty. Journal of Nursing Education, 46(1), 15–19. Luparell, S. (2011). Incivility in nursing: The connection between academia and clinical settings. Critical Care Nurse, 31, 92–95. MacKusick, C. I., & Minick, P. (2010). Why are nurses leaving? Findings from an initial qualitative study on nursing attrition. Medsurg Nursing, 19, 335–340. Mintz-Binder, R. D., & Calkins, R. D. (2012). Exposure to bullying at the associate degree nursing program director level. Teaching and Learning in Nursing, 7, 152–158.
Appendix Horizontal/Lateral Violence Workshop Pretest and Posttest Please provide answers to the following statements. Put a circle around the response that you feel best reflects your experience. 1. I hear about horizontal/lateral violence happening in school. Never 1
Seldom/Rarely 2
Sometimes 3
Often 4
Always 5
Often 4
Always 5
Often 4
Always 5
Often 4
Always 5
2. I hear about horizontal/lateral violence happening in the clinical setting. Never 1
Seldom/Rarely 2
Sometimes 3
3. I have been a victim of horizontal/lateral violence at school. Never 1
Seldom/Rarely 2
Sometimes 3
4. I have been a victim of horizontal/violence in the clinical setting. Never 1
Seldom/Rarely 2
Sometimes 3
5. I have known individuals who have engaged in horizontal/lateral violence at school. Never 1
Seldom/Rarely 2
Sometimes 3
Often 4
Always 5
6. I have known individuals who have engaged in horizontal/lateral violence in the clinical setting. Never 1
Seldom/Rarely 2
Sometimes 3
Often 4
Always 5
Often 4
Always 5
Often 4
Always 5
7. I have engaged in horizontal/lateral violence at school. Never 1
Seldom/Rarely 2
Sometimes 3
8. I have engaged in horizontal/lateral violence in the clinical setting. Never 1
Seldom/Rarely 2
Sometimes 3
245 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Antibullying Workshops
A. L. Egues and E. Z. Leinung
Please write your answer to the following questions: 1. How would you describe horizontal/lateral violence, and how does it make you feel? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________ 2. Can you describe an example of horizontal/lateral violence that you have seen or experienced and how you dealt with it? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ____________ Thank you for your time and consideration!
246 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
