Journal of Nursing Management, 2015, 23, 1106–1114
The impact of organisational factors on horizontal bullying and turnover intentions in the nursing workplace SHEILA BLACKSTOCK M S c N , B S c N , R N , C O H N 1, KAREN HARLOS 3 4 R N and CINDY L. HARDY P h D , R P s y c h
PhD, MA
2
, MARTHA L.P. MACLEOD
PhD,
1
Doctoral Student, School of Nursing, University of Alberta, Edmonton, Alberta, 2Associate Professor and Inaugural Chair, Department of Business and Administration, University of Winnipeg, Winnipeg, Manitoba, 3 Professor and Chair, School of Nursing, University of Northern British Columbia, Prince George, British Columbia and 4Professor and Chair, Department of Psychology, University of Northern British Columbia, Prince George, British Columbia, Canada
Correspondence Sheila Blackstock School of Nursing University of Alberta Edmonton Alberta Canada E-mail: [email protected]
BLACKSTOCK S., HARLOS K., MACLEOD M.L.P.,
& HARDY C.L. (2015) Journal of Nursing Management 23, 1106–1114. The impact of organisational factors on horizontal bullying and turnover intentions in the nursing workplace Aim To examine the impact of organisational factors on bullying among peers (i.e. horizontal) and its effect on turnover intentions among Canadian registered nurses (RNs). Background Bullying among nurses is an international problem. Few studies have examined factors specific to nursing work environments that may increase exposure to bullying. Methods An Australian model of nurse bullying was tested among Canadian registered nurse coworkers using a web-based survey (n = 103). Three factors – misuse of organisational processes/procedures, organisational tolerance and reward of bullying, and informal organisational alliances – were examined as predictors of horizontal bullying, which in turn was examined as a predictor of turnover intentions. The construct validity of model measures was explored. Results Informal organisational alliances and misuse of organisational processes/ procedures predicted increased horizontal bullying that, in turn, predicted increased turnover intentions. Construct validity of model measures was supported. Conclusion Negative informal alliances and misuse of organisational processes are antecedents to bullying, which adversely affects employment relationship stability. Implications for nursing management The results suggest that reforming flawed organisational processes that contribute to registered nurses’ bullying experiences may help to reduce chronically high turnover. Nurse leaders and managers need to create workplace processes that foster positive networks, fairness and respect through more transparent and accountable practices. Keywords: Canada, horizontal, registered nurses, turnover intentions, workplace
bullying Accepted for publication: 21 July 2014
Introduction As the World Health Organisation’s Health Workforce Decade (2006–15) draws to a close, stemming 1106
nurse turnover continues to be a key focus, given the high rates of turnover and high replacement costs (Tai et al. 1998), which in the USA range between $22 000 and $64 000 (US) per nurse (Jones & Gates DOI: 10.1111/jonm.12260 ª 2014 John Wiley & Sons Ltd
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2007). Voluntary turnover fuels the global shortage of nurses, now considered a crisis, given its scope and the declining quality of care it brings (Schalk et al. 2010). Global research across countries with similar nursing roles and hospital work environments has begun to illuminate common workplace and workforce issues contributing to nurse turnover (Duffield & O’Brien-Pallas 2002, Estryn-Behar et al. 2007, Aiken et al. 2011), offering insights into levers for retention that reduce costs while improving the quality of care. The current study adds to this international knowledge base by investigating the impact of organisational factors on horizontal bullying and turnover intentions in a Canadian nursing workplace. The results reported here represent the first known attempt to determine if the basic findings of a model of bullying derived in Australian nursing work environments (Hutchinson et al. 2008a, 2010) can be generalised to a different country and to a more specialised group: registered nurse (RN) coworkers. The current study examined the impact of three organisational factors – informal organisational alliances, organisational tolerance and reward of bullying, and misuse of organisational processes/procedures – on bullying among peers (i.e. horizontal) and, in turn, its effect on turnover intentions. Because the nursing workforce in Canada and Australia share common characteristics and issues (Duffield & O’Brien-Pallas 2002), we expected the model to generalise to a Canadian context and enhance evidence for improving management practice.
Background Over the past two decades, bullying among nurses across an array of specialties and designations, including RNs, has been shown to be a persistent problem nationally and internationally with strong links to turnover (Johnson 2009). For example, community nurses in the UK who had experienced bullying in the previous year reported significantly higher intentions to leave than nurses who were not bullied (Quine 2001). Exposure to bullying at work increases turnover of both targets and witnesses (Rayner 1998, Houshmand et al. 2012). A study of Danish health care workers showed that exposure to workplace bullying led to turnover not only one but also 2 years later (Hogh et al. 2011). Workplace bullying refers to repeated behaviours by organisational members that are offensive, often escalating in intensity with a perceived intent to harm (Einarsen et al. 2009). A growing volume of research ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1106–1114
has been collected on the deleterious effects of workplace bullying for individuals and organisations, including higher turnover, sickness and absence (Nielsen & Einarsen 2012). One study of Danish health care workers, including nurses, showed that frequent bullying leads to long-term sick leave (Ortega et al. 2011). More broadly, there is widespread agreement that workplace bullying, mistreatment and disrespect are commonly enacted through procedures, interactions and decisions that are regarded as fundamentally unfair (Folger & Cropanzano 1998, Miller 2001). Power imbalances between instigators and targets are commonly associated with workplace bullying. These imbalances can be structural, arising from different hierarchical levels in the organisation or they can be informal, relating to different personal attributes such as gender and ethnicity (Einarsen et al. 2009). Bullying appears especially pervasive among nurses at various career stages from student trainees (Ferns & Meerabeau 2009) to new graduates (Laschinger et al. 2010) to senior nurses (Kwok et al. 2006). Horizontal bullying has emerged as a serious concern in nursing workplaces worldwide (Ortega et al. 2011). A study of horizontal bullying among Turkish nurses reported their beliefs that co-workers would attempt to adversely influence rewards, work conditions and tasks, and job security in order to bully others (Katrinli et al. 2010). Given concerns about under-reporting of violence against nurses (Hutchinson et al. 2008a,b), it is clear that horizontal bullying and its sources need to be better understood by researchers and practice leaders. Studies that examine organisational factors conducive to bullying are consistent with the work environment hypothesis, which proposes that flawed work processes and other negative job conditions create stress and frustration that, in turn, prompt employees to behave aggressively toward each other (Hoel & Salin 2003). Further empirical work is needed, however, to establish the range of organisational factors related to bullying (Salin 2003). There is some evidence that unique characteristics and pressures of nursing work environments may lead to unique forms of bullying such as undervaluing others’ efforts, and isolation tactics (Quine 2001). In this vein, a multidimensional model was developed and tested in the Australian nursing workforce to measure the effects of flawed organisational processes on bullying exposure and, in turn, its impact on personal and work outcomes (Hutchinson et al. 2008a, 2010). The model was developed from inductive research that uncovered aspects of bullying embedded in procedures and 1107
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processes of nursing work environments. These bullying-based processes are believed to create conditions conducive to further bullying acts of intimidation, humiliation or denigration, reinforcing a sense of unfairness.
Theoretical framework According to results from Hutchinson et al. (2008a, 2010), three organisational factors appear to act as antecedents to bullying. The first factor, termed informal organisational alliances, refers to social and hierarchical networks among bullying perpetrators that support and protect them from challenge or reproach. The second factor, misuse of organisational processes/ procedures, describes ways that nurse bullying is enabled through decision-making and other work processes. The effect among targets of bullying includes the sense that they are overly scrutinised or held to unreasonable standards of conduct or performance, which undermine their confidence and efficacy. The third factor, organisational tolerance and reward of bullying, refers to the tendency for health organisations to condone or support bullying behaviours. In these work contexts, individuals who bully others are rewarded through promotion or other benefits despite their aggressive approach while those who stay silent in the face of others’ bullying are also rewarded. The current study sought further empirical support for this Australian model by examining whether a sample of RN coworkers in Canada would report experiences of similar organisational factors, workplace bullying and outcomes. This study also explored support for the construct validity of Australian measures using established measures in the psychological and organisational literatures. To our knowledge, no previous study has examined the validity of the model and its measures outside of Australia (personal communication, Hutchinson, 25 June 2012). On the basis of the literature reviewed, it was hypothesised that informal organisational alliances, organisational tolerance and reward of bullying, and misuse of organisational processes/procedures would predict bullying among RNs and that, when taken together, the impact of organisational factors on bullying, in turn, would predict turnover intentions, which are the most immediate psychological antecedent to voluntary turnover (Hom & Griffeth 1995). In testing the overall model, we controlled for the effects of organisational tenure given that nurses’ length of employment influences
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both planned and actual turnover (Ferris & Rowland 1987, Tai et al. 1998, Hayes et al. 2006).
Methods A total of 477 staff RNs working at a western Canadian hospital were invited to participate in a web-based survey administered through a passwordprotected internet site. Prior to the study launch, a research assistant and nurse manager reviewed the invitation list to exclude RNs working at higher or lower ranks (e.g. nursing managers, student nurses). Because the sample consists of nurse peers, survey responses thus reflect experiences of horizontal bullying. On survey completion, participants were eligible for a cash prize. A total of 103 surveys were returned (22%). It is not known how many RNs did not respond because they considered themselves ineligible (e.g. recent promotion). Thus, this response rate is an approximation – possibly underestimated. It is comparable to previous published research (25% in Kwok et al. 2006, 20% in Hutchinson et al. 2008a,b) and more robust than the original test of the multidimensional model on which the present study is based (7.4% in Hutchinson et al. 2010).
Data collection The survey, described as a study of worklife quality for staff RNs, was pilot tested among five retired RNs who provided in-depth feedback on length, clarity and measures. Only slight revisions were made in response to feedback. Study participants were sent an electronic cover letter via organisational e-mail containing a unique, secure site link to the survey. Information posters were displayed at key locations in the hospital and the first author held a series of ‘information tables’ to solicit participation. Several reminder e-mails were sent over 4 weeks in March 2010. Participants completed the survey either at home or at work.
Data analysis Version 17 for Windows (SPSS Inc., Chicago, IL, USA) was used to analyse the data. Initial screening to identify missing data resulted in the removal of nine cases missing 50% or more of data, leaving 94 surveys for analysis. Correlational tests examined the construct validity of model measures and hierarchical regression analyses were used to test hypotheses. For
SPSS
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multi-item scales, mean scores were derived for comparison and reporting. The sample size was not sufficient for structural equation modelling (SEM) and confirmatory factor analytic techniques used by Hutchinson et al. (2010), thus precluding direct comparison of results across studies. Instead we used regression analysis, preferable in the present situation given its suitability for samples under 100 cases and the ability it provides investigators to use proven remedial data transformation methods for violations of distribution assumptions (Gefen et al. 2000). The ratio of cases to predictors met standards recommended by Tabachnick and Fidell (2013) and statistical power was deemed adequate to detect medium size effects (i.e. b = 0.20).
Instruments Australian model measures Four measures applied in Hutchinson et al. (2010) were used in the current study. Misuse of organisational processes/procedures The degree to which participants experienced bullying enacted through decision making and failure to follow organisational procedures was measured using this 8-item scale (e.g. ‘Records of meetings are falsified’). The response scale for this and the following two measures was a 5-point Likert-type scale that ranged from 1 (strongly disagree) to 5 (strongly agree). Informal organisational alliances The degree to which participants perceived that social and hierarchical networks exist among bullying perpetrators that protect them was measured using this 5-item scale. An example item included ‘Bullies organise work to allow a group to target someone’. Organisational tolerance and reward of bullying This 6-item scale assessed the extent to which bullying behaviours were condoned or supported (e.g. ‘Regardless of what they do bullies get promoted’). Workplace bullying acts This was measured with the 9-item scale from Hutchinson et al. (2010) adapted from earlier work (Hutchinson et al. 2008b). Participants were asked to report how often they directly experienced bullying behaviours over the preceding 12 months on a 5-point frequency scale (1 = never to 5 = daily). Sample items included ‘I was excluded from receiving information’ ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1106–1114
and ‘I was publicly humiliated’. Additional support for the validity of the measure was sought through associations with established indices of workplace mistreatment and incivility.
Additional measures Fairness of interpersonal treatment The perceived fairness of interpersonal treatment in the organisation was measured using a 10-item, 3-point response scale (yes, ‘?’, no) developed by Donovan et al. (1998). Participants rated their overall experience of fair treatment (e.g. ‘In this organisation, employees are praised for good work’). Organisational support Registered nurses’ beliefs that the organisation values their contributions and cares for their well-being were measured using the eight-item scale developed by Lynch et al. (1999) with a 5-point Likert-type response scale (1 = strongly disagree; 5 = strongly agree). Workplace mistreatment Three dimensions of workplace mistreatment were measured with scales developed by Harlos and Axelrod (2005), and were validated as unfair by those who reported having experienced such treatment (Harlos & Axelrod 2008). The 8-item Verbal Abuse scale reflects spoken behaviours that are denigrating and demeaning, such as being yelled at or blamed for another’s mistakes. The 4-item Work Obstruction scale refers to blocks in getting work done such as failing to get needed resources or support, and having requests for information ignored. The Emotional Neglect scale used five items to measure the sense of abandonment when employee needs for socio-emotional support and recognition are ignored. In the current study, participants were asked to rate the frequency with which they had personally experienced each item in the previous 12 months using a 5-point scale (1 = never to 5 = daily). Workplace incivility This was measured with a seven-item scale developed by Cortina et al. (2001) and adapted here for the nursing workplace to capture participants’ interpersonal treatment by coworkers (e.g. ‘In the last 12 months, have you ever been in a situation where any of your coworkers ignored or excluded you from professional camaraderie?’). The scale asked participants to indicate the frequency with which they 1109
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(0.78) 0.32** (0.94) 0.45** 0.14 (0.92) 0.86** 0.56** 0.12. N for correlations range from 85 to 94. Cronbach’s alpha internal consistency reliability coefficients are indicated in parentheses on the diagonal. † 3-point scale; ‡5-point scale; §4-point scale. *P < 0.05; **P < 0.01; two-tailed tests of significance.
(0.85) 0.69** 0.67** 0.53** 0.17 (0.88) 0.24* 0.25* 0.27* 0.36** 0.31** (0.66) 0.39** 0.45** 0.44** 0.44** 0.64** 0.32** (0.81) 0.47** 0.20 0.35** 0.41** 0.31** 0.61** 0.20 (0.89) 0.68** 0.47** 0.17 0.39** 0.51** 0.43** 0.62** 0.11 (0.89) 0.39** 0.39** 0.55** 0.47** 0.37** 0.40** 0.35** 0.51** 0.43** (0.89) 0.68** 0.38** 0.37** 0.57** 0.53** 0.51** 0.58** 0.53** 0.56** 0.25* 0.08 0.01 0.09 0.05 0.02 0.13 0.06 0.06 0.05 0.11 0.54**
4 3 2 1 SD M Variable
Table 1 Means, standard deviations and intercorrelations of study variables
Participants were predominantly female (85%) and Caucasian (89%). The average age was 42 years, ranging from 26 to 60 years. Participants had worked in the hospital for an average of 11.8 years and were licensed in Canada as RNs for an average of 16 years. Means, standard deviations, intercorrelations and reliability estimates of study variables are listed in Table 1. Cronbach’s alphas for measures of the models’ three organisational factors and the bullying acts measure itself were 0.85, 0.92, 0.94 and 0.78, respectively, revealing adequate internal consistency. Correlations between these measures and other established measures from the organisational literature served as preliminary estimates of construct validity. The results showed that the bullying acts measure was positively correlated with established measures of workplace mistreatment (including dimensions of verbal abuse, emotional neglect and work obstruction) as well as workplace incivility. The three organisational factors were negatively correlated with organisational support and fair interpersonal treatment. All correlations were significant and in expected directions consistent with the purported meaning of the Hutchinson et al. (2010) measures and their interpretation as unfair. To prepare for regression analysis, analyses were performed to evaluate statistical assumptions (Gefen et al. 2000). This led to square root transformation to reduce positive skewness and kurtosis (Tabachnick & Fidell 2013) of the following variables: organisational processes/procedures, informal organisational alliances, tolerance and reward of bullying, and workplace bullying acts.
5
Results
8.63 0.48 0.79 0.82 0.51 0.73 0.85 0.62 1.15 1.16 0.41 0.94
6
7
8
Organisational tenure This control variable was assessed by asking participants to indicate the number of years they had been employed by the organisation in order to control for possible effects on the intention to leave as noted earlier.
11.8222 2.21† 2.90‡ 1.71‡ 1.48‡ 1.98‡ 3.80‡ 1.49‡ 1.96‡ 1.91‡ 1.33‡ 1.97§
9
10
Intention to leave This was measured with Ferris and Rowland’s (1987) single-item, four-point scale ranging from I intend to stay until I retire (1) to I intend to leave as soon as possible (4). Intention to leave is a strong predictor of actual leaving the job and this measure is widely used in nurse turnover research (Hayes et al. 2006).
1. Organisational tenure (years) 2. Fairness of interpersonal treatment 3. Organisational support 4. Workplace incivility 5. Verbal abuse 6. Work obstruction 7. Emotional neglect 8. Misuse of organisational processes 9. Informal organisational alliances 10. Organisational tolerance and reward of bullying 11. Workplace bullying acts 12. Intent to leave
11
12
experienced such behaviours from 1 (never) to 5 (most of the time).
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Effects of organisational factors on workplace bullying To examine the effects of organisational factors on horizontal bullying, standard multiple regression was used. Listwise deletion, the most conservative method of dealing with missing data, resulted in a useable sample of 90 cases for this analysis. With all organisational factors in the regression equation, R = 0.59, F(3, 86) = 15.06, P < 0.001. As shown in Table 2, the results indicate that two of three factors contributed significantly to predicting bullying. The significant increment was largely attributable to informal organisational alliances (b = 0.49, P < 0.05) and, to a lesser degree, misuse of organisational processes/procedures (b = 0.27, P < 0.05).
Effects of organisational factors and workplace bullying on intent to leave To examine the predictive power of the model, hierarchical regression was conducted in a three-step regression equation. In this procedure, independent variables presumed by theory to be causally prior are given higher order of entry above and beyond effects from control variables (Tabachnick & Fidell 2013). In accordance with Hutchinson et al. (2010), the three organisational factors presumed antecedent to workplace bullying were entered prior to bullying itself in predicting the intention to leave. Two cases were missing data for organisational tenure, a control variable, and thus mean substitution was used to estimate their scores. Listwise deletion of missing data among independent variables left a useable sample of 90 cases. Table 3 shows the standardised regression coefficients (b), and R2 after entry of variables at each step. Organisational tenure was entered as a control variable in the first step. In Step 2, the square roots of three organisational factors were entered consistent with their roles as antecedents (Hutchinson et al. Table 2 Hierarchical regression analysis: workplace bullying acts† b Misuse of organisational processes/procedures† Informal organisational alliances† Tolerance and reward of bullying† DR2 Overall F
0.27* 0.49* 0.14 15.06**
Standardised regression coefficients are presented. N = 90. Square root transformation of variables. *P < 0.05, **P < 0.001. †
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t 2.20 2.57 0.78 0.34**
2010) followed in Step 3 by the square root of workplace bullying. After Step 3, with all variables in the equation, R = 0.60, F(5, 84) = 9.32, P < 0.001. After Step 1, with organisational tenure in the equation, R2 = 0.28 F(1, 88), P < 0.001. After Step 2, with the square roots of organisational factors added to the prediction of intent to leave, there was no reliable improvement in R2. After Step 3, adding the square root of bullying significantly improved prediction of the intent to leave beyond the influences of organisational tenure and organisational factors from nursing work environments (b = 0.23, P < 0.05).
Discussion We found evidence that nurses’ perceptions of informal organisational alliances and misuse of organisational processes/procedures predicted experiences of workplace bullying, which in turn predicted the intent to leave after adjusting for effects of organisational tenure consistent with the theoretical framework underlying this study (Hutchinson et al. 2010) and, more generally, the work environment hypothesis. We also found evidence supporting the construct validity of measures for organisational antecedent factors and workplace bullying acts developed by Hutchinson et al. (2010) among Australian nurses. These results extend support for the Australian model to an international setting and to peer RN relationships. Although RNs at the same hierarchical level may not have formal capacity to build alliances or training in effective management practices, nonetheless there are nuanced situations that can foster bullying. For example, acting charge RNs who provide temporary leadership when head nurses are absent (e.g. evenings, weekends) might have provisional authority over a coworker. Although the negative relationship between organisational support and turnover intentions reported here suggests that RNs felt cared for by the organisation as a whole, this might not be true in some wards or departments. Future studies with larger samples would allow measurement of unit-level variations in social support to shed light on its possible role in mediating or buffering influences from informal alliances of ‘nasty networks’ and misuse of organisational processes on workplace bullying, and on its possible role in the buffering effects of workplace bullying acts on RNs turnover intentions. Overall, findings from Hutchinson et al.’s (2010) Australian study and this Canadian study suggest at least two changes are needed to reduce the occurrence of flawed organisational procedures that spur subse1111
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Table 3 Hierarchical regression analysis: intent to leave Model 1 b Step 1 Organisational tenure DR2 Step 2 Misuse of organisational processes/procedures† Informal organisational alliances† Tolerance and reward of bullying† DR2 Step 3 Workplace bullying acts† DR2 Overall model R2 Overall F
0.53** 0.28**
Model 2 t
5.85
Model 3
b
t
b
t
0.54**
–
0.51**
5.70
0.20
1.59
0.14
1.07
0.01 0.02
– 0.10
0.13 0.06
0.65 0.31
0.23* 0.03* 0.36
2.11
0.04
9.32**
Standardised regression coefficients are presented. N = 90. Square root transformation of variables. *P < 0.05, **P < 0.001. †
quent exposure to workplace bullying acts and to dissuade RNs from planning to quit. First, interventions are needed to reduce the extent to which informal alliances that promote bullying are allowed to form and exert influence. Although the very informality of such social and hierarchical networks makes them difficult to identify and influence, explicit efforts to increase transparency and accountability are needed to thwart groups’ attempts to coerce or intimidate others while protecting themselves from scrutiny or responsibility. When bolstered by organisational policies fostering respect at work, constructive communication and effective conflict resolution, alliances of nasty networks can be made more accountable. In nursing workplaces, managers and leaders play key roles in strengthening respect and collegiality by monitoring overall interpersonal relations and reforming practices and procedures as needed to support the quality of the work environment and its positive impact on stable staffing, employee well-being and quality of care. Second, such reform of flawed organisational procedures would benefit from knowledge of fair process principles and practices. According to Kim and Mauborgne (1997), engagement to produce ideas, explanation for decisions and clear expectations for implementation are critical for a motivated workforce that supports managerial initiatives and organisational goals, especially in today’s knowledge-based organisations (which include hospitals) and among knowledge workers (such as RNs). Our data suggest that embedding fair process tenets into the design and implementation of organisational procedures should help to 1112
reduce the degree to which RNs are exposed to bullying acts. This study shares limitations common to single-site studies using cross-sectional survey data and regression analysis. These centre on the inability to make inferences about causality or extend results beyond the current sample. Thus, research is needed beyond this single health care organisation and beyond acute care RNs. Larger samples of nurses with greater specialty diversity and professional designations would assist in the further investigation of the generalisability of the multidimensional model. The use of self-report measures makes it possible that common source bias may have inflated results. Arguably, however, self-report is optimal for the sensitive data sought here. Although measuring actual turnover is preferable to turnover intentions, applying Ferris and Rowland’s (1987) wellestablished measure in this study helps to alleviate concern about intentions as a proxy for actual turnover.
Conclusion Although there is a strong theoretical foundation for the role of organisational factors in creating conditions conducive to bullying, these factors seldom have been examined within nurse work environments and across international contexts. Such evidence is useful for customised strategies to manage and prevent nurse bullying. Findings from this study indicate that flawed organisational processes and unofficial alliances that isolate and intimidate nurses contribute to exposure to bullying among peers, which in turn increases nurses’ plans to ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1106–1114
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leave the organisation. Negative informal alliances and unfair workplace processes reduce RNs’ employment relationship stability. Organisational reforms that create work environments known for respect and fairness will build RNs’ capacity to be treated and treat others with more care and compassion.
Source of funding The study was supported by the Social Science and Humanities Research Council of Canada (SSHRC 410-2006-0669).
References Implications for nursing management This study provides two significant implications for nursing management. The first is that there is the promise of relief from chronic problems of unstable staffing levels through identifying and mitigating organisational factors that underlie the exodus of RNs as a result of bullying. Recognising nasty networks and restoring healthy informal alliances interwoven with positive social networks will allow nursing managers to take steps towards promoting respectful regular interactions. By implementing workplace practices that promote accountability and transparency the formation of negative informal alliances and their influence may be reduced. Such efforts may be more effective when complemented by skills-based training in communication and conflict management to aid in monitoring and resolving problematic practices before they negatively impact work relationships. The second critical step is to embed fair process principles into workplace decision-making and resource allocation processes. The experience of such fair processes in workplaces should enable RNs in turn to care for individuals, families and communities in a respectful and dignified manner.
Acknowledgements This study, based on the first author’s thesis research, was funded by a grant to the second author from the Social Sciences and Humanities Research Council of Canada. Earlier findings were presented at the International Conference on Violence in the Health Sector, Vancouver BC, October 2012. We thank the health authority, nursing managers and registered nurses who participated in the pilot and main studies.
Ethical approval The study was approved by institutional review boards at two universities and the host hospital. Indication of participation consent was provided by completing the survey. All identifying information was stripped prior to entry into the survey database for anonymity. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1106–1114
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hospital settings. Journal of Advanced Nursing 66, 2732– 2742. Lynch P., Eisenberger R. & Armeli S. (1999) Perceived organizational support: inferior versus superior performance by wary employees. Journal of Applied Psychology 84, 467– 483. Miller D. (2001) Disrespect and the experience of injustice. Annual Review of Psychology 52, 527–553. Nielsen M.B. & Einarsen S. (2012) Outcomes of workplace bullying. A meta-analytic review. Work & Stress 26 (4), 309– 332. Ortega A., Christensen K.B., Hogh A., Rugulies R. & Borg V. (2011) One-year prospective study on the effect of workplace bullying on long-term sickness absence. Journal of Nursing Management 19, 752–759. Quine L. (2001) Workplace bullying in nurses. Journal of Health Psychology 6, 73–84. Rayner C. (1998) Workplace bullying: do something!. The Journal of Occupational Health and Safety – Australia and New Zealand 14, 581–585. Salin D. (2003) Ways of explaining workplace bullying: a review of enabling, motivating and precipitating structures and processes in the work environment. Human Relations 56, 1213–1232. Schalk D., Bijl M., Halfens R., Hollands L. & Cummings G. (2010) Interventions aimed at improving the nursing work environment: a systematic review. Implementation Science 5, 34. Tabachnick B. & Fidell L. (2013) Using Multivariate Statistics, 6th edn. Pearson Education, Upper Saddle River, NJ. Tai T., Bame S. & Robinson C. (1998) Review of nursing turnover research, 1977–1996. Social Science & Medicine 47, 1905–1924.
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The impact of organisational factors on horizontal bullying and turnover intentions in the nursing workplace SHEILA BLACKSTOCK M S c N , B S c N , R N , C O H N 1, KAREN HARLOS 3 4 R N and CINDY L. HARDY P h D , R P s y c h
PhD, MA
2
, MARTHA L.P. MACLEOD
PhD,
1
Doctoral Student, School of Nursing, University of Alberta, Edmonton, Alberta, 2Associate Professor and Inaugural Chair, Department of Business and Administration, University of Winnipeg, Winnipeg, Manitoba, 3 Professor and Chair, School of Nursing, University of Northern British Columbia, Prince George, British Columbia and 4Professor and Chair, Department of Psychology, University of Northern British Columbia, Prince George, British Columbia, Canada
Correspondence Sheila Blackstock School of Nursing University of Alberta Edmonton Alberta Canada E-mail: [email protected]
BLACKSTOCK S., HARLOS K., MACLEOD M.L.P.,
& HARDY C.L. (2015) Journal of Nursing Management 23, 1106–1114. The impact of organisational factors on horizontal bullying and turnover intentions in the nursing workplace Aim To examine the impact of organisational factors on bullying among peers (i.e. horizontal) and its effect on turnover intentions among Canadian registered nurses (RNs). Background Bullying among nurses is an international problem. Few studies have examined factors specific to nursing work environments that may increase exposure to bullying. Methods An Australian model of nurse bullying was tested among Canadian registered nurse coworkers using a web-based survey (n = 103). Three factors – misuse of organisational processes/procedures, organisational tolerance and reward of bullying, and informal organisational alliances – were examined as predictors of horizontal bullying, which in turn was examined as a predictor of turnover intentions. The construct validity of model measures was explored. Results Informal organisational alliances and misuse of organisational processes/ procedures predicted increased horizontal bullying that, in turn, predicted increased turnover intentions. Construct validity of model measures was supported. Conclusion Negative informal alliances and misuse of organisational processes are antecedents to bullying, which adversely affects employment relationship stability. Implications for nursing management The results suggest that reforming flawed organisational processes that contribute to registered nurses’ bullying experiences may help to reduce chronically high turnover. Nurse leaders and managers need to create workplace processes that foster positive networks, fairness and respect through more transparent and accountable practices. Keywords: Canada, horizontal, registered nurses, turnover intentions, workplace
bullying Accepted for publication: 21 July 2014
Introduction As the World Health Organisation’s Health Workforce Decade (2006–15) draws to a close, stemming 1106
nurse turnover continues to be a key focus, given the high rates of turnover and high replacement costs (Tai et al. 1998), which in the USA range between $22 000 and $64 000 (US) per nurse (Jones & Gates DOI: 10.1111/jonm.12260 ª 2014 John Wiley & Sons Ltd
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2007). Voluntary turnover fuels the global shortage of nurses, now considered a crisis, given its scope and the declining quality of care it brings (Schalk et al. 2010). Global research across countries with similar nursing roles and hospital work environments has begun to illuminate common workplace and workforce issues contributing to nurse turnover (Duffield & O’Brien-Pallas 2002, Estryn-Behar et al. 2007, Aiken et al. 2011), offering insights into levers for retention that reduce costs while improving the quality of care. The current study adds to this international knowledge base by investigating the impact of organisational factors on horizontal bullying and turnover intentions in a Canadian nursing workplace. The results reported here represent the first known attempt to determine if the basic findings of a model of bullying derived in Australian nursing work environments (Hutchinson et al. 2008a, 2010) can be generalised to a different country and to a more specialised group: registered nurse (RN) coworkers. The current study examined the impact of three organisational factors – informal organisational alliances, organisational tolerance and reward of bullying, and misuse of organisational processes/procedures – on bullying among peers (i.e. horizontal) and, in turn, its effect on turnover intentions. Because the nursing workforce in Canada and Australia share common characteristics and issues (Duffield & O’Brien-Pallas 2002), we expected the model to generalise to a Canadian context and enhance evidence for improving management practice.
Background Over the past two decades, bullying among nurses across an array of specialties and designations, including RNs, has been shown to be a persistent problem nationally and internationally with strong links to turnover (Johnson 2009). For example, community nurses in the UK who had experienced bullying in the previous year reported significantly higher intentions to leave than nurses who were not bullied (Quine 2001). Exposure to bullying at work increases turnover of both targets and witnesses (Rayner 1998, Houshmand et al. 2012). A study of Danish health care workers showed that exposure to workplace bullying led to turnover not only one but also 2 years later (Hogh et al. 2011). Workplace bullying refers to repeated behaviours by organisational members that are offensive, often escalating in intensity with a perceived intent to harm (Einarsen et al. 2009). A growing volume of research ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1106–1114
has been collected on the deleterious effects of workplace bullying for individuals and organisations, including higher turnover, sickness and absence (Nielsen & Einarsen 2012). One study of Danish health care workers, including nurses, showed that frequent bullying leads to long-term sick leave (Ortega et al. 2011). More broadly, there is widespread agreement that workplace bullying, mistreatment and disrespect are commonly enacted through procedures, interactions and decisions that are regarded as fundamentally unfair (Folger & Cropanzano 1998, Miller 2001). Power imbalances between instigators and targets are commonly associated with workplace bullying. These imbalances can be structural, arising from different hierarchical levels in the organisation or they can be informal, relating to different personal attributes such as gender and ethnicity (Einarsen et al. 2009). Bullying appears especially pervasive among nurses at various career stages from student trainees (Ferns & Meerabeau 2009) to new graduates (Laschinger et al. 2010) to senior nurses (Kwok et al. 2006). Horizontal bullying has emerged as a serious concern in nursing workplaces worldwide (Ortega et al. 2011). A study of horizontal bullying among Turkish nurses reported their beliefs that co-workers would attempt to adversely influence rewards, work conditions and tasks, and job security in order to bully others (Katrinli et al. 2010). Given concerns about under-reporting of violence against nurses (Hutchinson et al. 2008a,b), it is clear that horizontal bullying and its sources need to be better understood by researchers and practice leaders. Studies that examine organisational factors conducive to bullying are consistent with the work environment hypothesis, which proposes that flawed work processes and other negative job conditions create stress and frustration that, in turn, prompt employees to behave aggressively toward each other (Hoel & Salin 2003). Further empirical work is needed, however, to establish the range of organisational factors related to bullying (Salin 2003). There is some evidence that unique characteristics and pressures of nursing work environments may lead to unique forms of bullying such as undervaluing others’ efforts, and isolation tactics (Quine 2001). In this vein, a multidimensional model was developed and tested in the Australian nursing workforce to measure the effects of flawed organisational processes on bullying exposure and, in turn, its impact on personal and work outcomes (Hutchinson et al. 2008a, 2010). The model was developed from inductive research that uncovered aspects of bullying embedded in procedures and 1107
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processes of nursing work environments. These bullying-based processes are believed to create conditions conducive to further bullying acts of intimidation, humiliation or denigration, reinforcing a sense of unfairness.
Theoretical framework According to results from Hutchinson et al. (2008a, 2010), three organisational factors appear to act as antecedents to bullying. The first factor, termed informal organisational alliances, refers to social and hierarchical networks among bullying perpetrators that support and protect them from challenge or reproach. The second factor, misuse of organisational processes/ procedures, describes ways that nurse bullying is enabled through decision-making and other work processes. The effect among targets of bullying includes the sense that they are overly scrutinised or held to unreasonable standards of conduct or performance, which undermine their confidence and efficacy. The third factor, organisational tolerance and reward of bullying, refers to the tendency for health organisations to condone or support bullying behaviours. In these work contexts, individuals who bully others are rewarded through promotion or other benefits despite their aggressive approach while those who stay silent in the face of others’ bullying are also rewarded. The current study sought further empirical support for this Australian model by examining whether a sample of RN coworkers in Canada would report experiences of similar organisational factors, workplace bullying and outcomes. This study also explored support for the construct validity of Australian measures using established measures in the psychological and organisational literatures. To our knowledge, no previous study has examined the validity of the model and its measures outside of Australia (personal communication, Hutchinson, 25 June 2012). On the basis of the literature reviewed, it was hypothesised that informal organisational alliances, organisational tolerance and reward of bullying, and misuse of organisational processes/procedures would predict bullying among RNs and that, when taken together, the impact of organisational factors on bullying, in turn, would predict turnover intentions, which are the most immediate psychological antecedent to voluntary turnover (Hom & Griffeth 1995). In testing the overall model, we controlled for the effects of organisational tenure given that nurses’ length of employment influences
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both planned and actual turnover (Ferris & Rowland 1987, Tai et al. 1998, Hayes et al. 2006).
Methods A total of 477 staff RNs working at a western Canadian hospital were invited to participate in a web-based survey administered through a passwordprotected internet site. Prior to the study launch, a research assistant and nurse manager reviewed the invitation list to exclude RNs working at higher or lower ranks (e.g. nursing managers, student nurses). Because the sample consists of nurse peers, survey responses thus reflect experiences of horizontal bullying. On survey completion, participants were eligible for a cash prize. A total of 103 surveys were returned (22%). It is not known how many RNs did not respond because they considered themselves ineligible (e.g. recent promotion). Thus, this response rate is an approximation – possibly underestimated. It is comparable to previous published research (25% in Kwok et al. 2006, 20% in Hutchinson et al. 2008a,b) and more robust than the original test of the multidimensional model on which the present study is based (7.4% in Hutchinson et al. 2010).
Data collection The survey, described as a study of worklife quality for staff RNs, was pilot tested among five retired RNs who provided in-depth feedback on length, clarity and measures. Only slight revisions were made in response to feedback. Study participants were sent an electronic cover letter via organisational e-mail containing a unique, secure site link to the survey. Information posters were displayed at key locations in the hospital and the first author held a series of ‘information tables’ to solicit participation. Several reminder e-mails were sent over 4 weeks in March 2010. Participants completed the survey either at home or at work.
Data analysis Version 17 for Windows (SPSS Inc., Chicago, IL, USA) was used to analyse the data. Initial screening to identify missing data resulted in the removal of nine cases missing 50% or more of data, leaving 94 surveys for analysis. Correlational tests examined the construct validity of model measures and hierarchical regression analyses were used to test hypotheses. For
SPSS
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multi-item scales, mean scores were derived for comparison and reporting. The sample size was not sufficient for structural equation modelling (SEM) and confirmatory factor analytic techniques used by Hutchinson et al. (2010), thus precluding direct comparison of results across studies. Instead we used regression analysis, preferable in the present situation given its suitability for samples under 100 cases and the ability it provides investigators to use proven remedial data transformation methods for violations of distribution assumptions (Gefen et al. 2000). The ratio of cases to predictors met standards recommended by Tabachnick and Fidell (2013) and statistical power was deemed adequate to detect medium size effects (i.e. b = 0.20).
Instruments Australian model measures Four measures applied in Hutchinson et al. (2010) were used in the current study. Misuse of organisational processes/procedures The degree to which participants experienced bullying enacted through decision making and failure to follow organisational procedures was measured using this 8-item scale (e.g. ‘Records of meetings are falsified’). The response scale for this and the following two measures was a 5-point Likert-type scale that ranged from 1 (strongly disagree) to 5 (strongly agree). Informal organisational alliances The degree to which participants perceived that social and hierarchical networks exist among bullying perpetrators that protect them was measured using this 5-item scale. An example item included ‘Bullies organise work to allow a group to target someone’. Organisational tolerance and reward of bullying This 6-item scale assessed the extent to which bullying behaviours were condoned or supported (e.g. ‘Regardless of what they do bullies get promoted’). Workplace bullying acts This was measured with the 9-item scale from Hutchinson et al. (2010) adapted from earlier work (Hutchinson et al. 2008b). Participants were asked to report how often they directly experienced bullying behaviours over the preceding 12 months on a 5-point frequency scale (1 = never to 5 = daily). Sample items included ‘I was excluded from receiving information’ ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1106–1114
and ‘I was publicly humiliated’. Additional support for the validity of the measure was sought through associations with established indices of workplace mistreatment and incivility.
Additional measures Fairness of interpersonal treatment The perceived fairness of interpersonal treatment in the organisation was measured using a 10-item, 3-point response scale (yes, ‘?’, no) developed by Donovan et al. (1998). Participants rated their overall experience of fair treatment (e.g. ‘In this organisation, employees are praised for good work’). Organisational support Registered nurses’ beliefs that the organisation values their contributions and cares for their well-being were measured using the eight-item scale developed by Lynch et al. (1999) with a 5-point Likert-type response scale (1 = strongly disagree; 5 = strongly agree). Workplace mistreatment Three dimensions of workplace mistreatment were measured with scales developed by Harlos and Axelrod (2005), and were validated as unfair by those who reported having experienced such treatment (Harlos & Axelrod 2008). The 8-item Verbal Abuse scale reflects spoken behaviours that are denigrating and demeaning, such as being yelled at or blamed for another’s mistakes. The 4-item Work Obstruction scale refers to blocks in getting work done such as failing to get needed resources or support, and having requests for information ignored. The Emotional Neglect scale used five items to measure the sense of abandonment when employee needs for socio-emotional support and recognition are ignored. In the current study, participants were asked to rate the frequency with which they had personally experienced each item in the previous 12 months using a 5-point scale (1 = never to 5 = daily). Workplace incivility This was measured with a seven-item scale developed by Cortina et al. (2001) and adapted here for the nursing workplace to capture participants’ interpersonal treatment by coworkers (e.g. ‘In the last 12 months, have you ever been in a situation where any of your coworkers ignored or excluded you from professional camaraderie?’). The scale asked participants to indicate the frequency with which they 1109
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1110
(0.78) 0.32** (0.94) 0.45** 0.14 (0.92) 0.86** 0.56** 0.12. N for correlations range from 85 to 94. Cronbach’s alpha internal consistency reliability coefficients are indicated in parentheses on the diagonal. † 3-point scale; ‡5-point scale; §4-point scale. *P < 0.05; **P < 0.01; two-tailed tests of significance.
(0.85) 0.69** 0.67** 0.53** 0.17 (0.88) 0.24* 0.25* 0.27* 0.36** 0.31** (0.66) 0.39** 0.45** 0.44** 0.44** 0.64** 0.32** (0.81) 0.47** 0.20 0.35** 0.41** 0.31** 0.61** 0.20 (0.89) 0.68** 0.47** 0.17 0.39** 0.51** 0.43** 0.62** 0.11 (0.89) 0.39** 0.39** 0.55** 0.47** 0.37** 0.40** 0.35** 0.51** 0.43** (0.89) 0.68** 0.38** 0.37** 0.57** 0.53** 0.51** 0.58** 0.53** 0.56** 0.25* 0.08 0.01 0.09 0.05 0.02 0.13 0.06 0.06 0.05 0.11 0.54**
4 3 2 1 SD M Variable
Table 1 Means, standard deviations and intercorrelations of study variables
Participants were predominantly female (85%) and Caucasian (89%). The average age was 42 years, ranging from 26 to 60 years. Participants had worked in the hospital for an average of 11.8 years and were licensed in Canada as RNs for an average of 16 years. Means, standard deviations, intercorrelations and reliability estimates of study variables are listed in Table 1. Cronbach’s alphas for measures of the models’ three organisational factors and the bullying acts measure itself were 0.85, 0.92, 0.94 and 0.78, respectively, revealing adequate internal consistency. Correlations between these measures and other established measures from the organisational literature served as preliminary estimates of construct validity. The results showed that the bullying acts measure was positively correlated with established measures of workplace mistreatment (including dimensions of verbal abuse, emotional neglect and work obstruction) as well as workplace incivility. The three organisational factors were negatively correlated with organisational support and fair interpersonal treatment. All correlations were significant and in expected directions consistent with the purported meaning of the Hutchinson et al. (2010) measures and their interpretation as unfair. To prepare for regression analysis, analyses were performed to evaluate statistical assumptions (Gefen et al. 2000). This led to square root transformation to reduce positive skewness and kurtosis (Tabachnick & Fidell 2013) of the following variables: organisational processes/procedures, informal organisational alliances, tolerance and reward of bullying, and workplace bullying acts.
5
Results
8.63 0.48 0.79 0.82 0.51 0.73 0.85 0.62 1.15 1.16 0.41 0.94
6
7
8
Organisational tenure This control variable was assessed by asking participants to indicate the number of years they had been employed by the organisation in order to control for possible effects on the intention to leave as noted earlier.
11.8222 2.21† 2.90‡ 1.71‡ 1.48‡ 1.98‡ 3.80‡ 1.49‡ 1.96‡ 1.91‡ 1.33‡ 1.97§
9
10
Intention to leave This was measured with Ferris and Rowland’s (1987) single-item, four-point scale ranging from I intend to stay until I retire (1) to I intend to leave as soon as possible (4). Intention to leave is a strong predictor of actual leaving the job and this measure is widely used in nurse turnover research (Hayes et al. 2006).
1. Organisational tenure (years) 2. Fairness of interpersonal treatment 3. Organisational support 4. Workplace incivility 5. Verbal abuse 6. Work obstruction 7. Emotional neglect 8. Misuse of organisational processes 9. Informal organisational alliances 10. Organisational tolerance and reward of bullying 11. Workplace bullying acts 12. Intent to leave
11
12
experienced such behaviours from 1 (never) to 5 (most of the time).
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Effects of organisational factors on workplace bullying To examine the effects of organisational factors on horizontal bullying, standard multiple regression was used. Listwise deletion, the most conservative method of dealing with missing data, resulted in a useable sample of 90 cases for this analysis. With all organisational factors in the regression equation, R = 0.59, F(3, 86) = 15.06, P < 0.001. As shown in Table 2, the results indicate that two of three factors contributed significantly to predicting bullying. The significant increment was largely attributable to informal organisational alliances (b = 0.49, P < 0.05) and, to a lesser degree, misuse of organisational processes/procedures (b = 0.27, P < 0.05).
Effects of organisational factors and workplace bullying on intent to leave To examine the predictive power of the model, hierarchical regression was conducted in a three-step regression equation. In this procedure, independent variables presumed by theory to be causally prior are given higher order of entry above and beyond effects from control variables (Tabachnick & Fidell 2013). In accordance with Hutchinson et al. (2010), the three organisational factors presumed antecedent to workplace bullying were entered prior to bullying itself in predicting the intention to leave. Two cases were missing data for organisational tenure, a control variable, and thus mean substitution was used to estimate their scores. Listwise deletion of missing data among independent variables left a useable sample of 90 cases. Table 3 shows the standardised regression coefficients (b), and R2 after entry of variables at each step. Organisational tenure was entered as a control variable in the first step. In Step 2, the square roots of three organisational factors were entered consistent with their roles as antecedents (Hutchinson et al. Table 2 Hierarchical regression analysis: workplace bullying acts† b Misuse of organisational processes/procedures† Informal organisational alliances† Tolerance and reward of bullying† DR2 Overall F
0.27* 0.49* 0.14 15.06**
Standardised regression coefficients are presented. N = 90. Square root transformation of variables. *P < 0.05, **P < 0.001. †
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t 2.20 2.57 0.78 0.34**
2010) followed in Step 3 by the square root of workplace bullying. After Step 3, with all variables in the equation, R = 0.60, F(5, 84) = 9.32, P < 0.001. After Step 1, with organisational tenure in the equation, R2 = 0.28 F(1, 88), P < 0.001. After Step 2, with the square roots of organisational factors added to the prediction of intent to leave, there was no reliable improvement in R2. After Step 3, adding the square root of bullying significantly improved prediction of the intent to leave beyond the influences of organisational tenure and organisational factors from nursing work environments (b = 0.23, P < 0.05).
Discussion We found evidence that nurses’ perceptions of informal organisational alliances and misuse of organisational processes/procedures predicted experiences of workplace bullying, which in turn predicted the intent to leave after adjusting for effects of organisational tenure consistent with the theoretical framework underlying this study (Hutchinson et al. 2010) and, more generally, the work environment hypothesis. We also found evidence supporting the construct validity of measures for organisational antecedent factors and workplace bullying acts developed by Hutchinson et al. (2010) among Australian nurses. These results extend support for the Australian model to an international setting and to peer RN relationships. Although RNs at the same hierarchical level may not have formal capacity to build alliances or training in effective management practices, nonetheless there are nuanced situations that can foster bullying. For example, acting charge RNs who provide temporary leadership when head nurses are absent (e.g. evenings, weekends) might have provisional authority over a coworker. Although the negative relationship between organisational support and turnover intentions reported here suggests that RNs felt cared for by the organisation as a whole, this might not be true in some wards or departments. Future studies with larger samples would allow measurement of unit-level variations in social support to shed light on its possible role in mediating or buffering influences from informal alliances of ‘nasty networks’ and misuse of organisational processes on workplace bullying, and on its possible role in the buffering effects of workplace bullying acts on RNs turnover intentions. Overall, findings from Hutchinson et al.’s (2010) Australian study and this Canadian study suggest at least two changes are needed to reduce the occurrence of flawed organisational procedures that spur subse1111
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Table 3 Hierarchical regression analysis: intent to leave Model 1 b Step 1 Organisational tenure DR2 Step 2 Misuse of organisational processes/procedures† Informal organisational alliances† Tolerance and reward of bullying† DR2 Step 3 Workplace bullying acts† DR2 Overall model R2 Overall F
0.53** 0.28**
Model 2 t
5.85
Model 3
b
t
b
t
0.54**
–
0.51**
5.70
0.20
1.59
0.14
1.07
0.01 0.02
– 0.10
0.13 0.06
0.65 0.31
0.23* 0.03* 0.36
2.11
0.04
9.32**
Standardised regression coefficients are presented. N = 90. Square root transformation of variables. *P < 0.05, **P < 0.001. †
quent exposure to workplace bullying acts and to dissuade RNs from planning to quit. First, interventions are needed to reduce the extent to which informal alliances that promote bullying are allowed to form and exert influence. Although the very informality of such social and hierarchical networks makes them difficult to identify and influence, explicit efforts to increase transparency and accountability are needed to thwart groups’ attempts to coerce or intimidate others while protecting themselves from scrutiny or responsibility. When bolstered by organisational policies fostering respect at work, constructive communication and effective conflict resolution, alliances of nasty networks can be made more accountable. In nursing workplaces, managers and leaders play key roles in strengthening respect and collegiality by monitoring overall interpersonal relations and reforming practices and procedures as needed to support the quality of the work environment and its positive impact on stable staffing, employee well-being and quality of care. Second, such reform of flawed organisational procedures would benefit from knowledge of fair process principles and practices. According to Kim and Mauborgne (1997), engagement to produce ideas, explanation for decisions and clear expectations for implementation are critical for a motivated workforce that supports managerial initiatives and organisational goals, especially in today’s knowledge-based organisations (which include hospitals) and among knowledge workers (such as RNs). Our data suggest that embedding fair process tenets into the design and implementation of organisational procedures should help to 1112
reduce the degree to which RNs are exposed to bullying acts. This study shares limitations common to single-site studies using cross-sectional survey data and regression analysis. These centre on the inability to make inferences about causality or extend results beyond the current sample. Thus, research is needed beyond this single health care organisation and beyond acute care RNs. Larger samples of nurses with greater specialty diversity and professional designations would assist in the further investigation of the generalisability of the multidimensional model. The use of self-report measures makes it possible that common source bias may have inflated results. Arguably, however, self-report is optimal for the sensitive data sought here. Although measuring actual turnover is preferable to turnover intentions, applying Ferris and Rowland’s (1987) wellestablished measure in this study helps to alleviate concern about intentions as a proxy for actual turnover.
Conclusion Although there is a strong theoretical foundation for the role of organisational factors in creating conditions conducive to bullying, these factors seldom have been examined within nurse work environments and across international contexts. Such evidence is useful for customised strategies to manage and prevent nurse bullying. Findings from this study indicate that flawed organisational processes and unofficial alliances that isolate and intimidate nurses contribute to exposure to bullying among peers, which in turn increases nurses’ plans to ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1106–1114
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leave the organisation. Negative informal alliances and unfair workplace processes reduce RNs’ employment relationship stability. Organisational reforms that create work environments known for respect and fairness will build RNs’ capacity to be treated and treat others with more care and compassion.
Source of funding The study was supported by the Social Science and Humanities Research Council of Canada (SSHRC 410-2006-0669).
References Implications for nursing management This study provides two significant implications for nursing management. The first is that there is the promise of relief from chronic problems of unstable staffing levels through identifying and mitigating organisational factors that underlie the exodus of RNs as a result of bullying. Recognising nasty networks and restoring healthy informal alliances interwoven with positive social networks will allow nursing managers to take steps towards promoting respectful regular interactions. By implementing workplace practices that promote accountability and transparency the formation of negative informal alliances and their influence may be reduced. Such efforts may be more effective when complemented by skills-based training in communication and conflict management to aid in monitoring and resolving problematic practices before they negatively impact work relationships. The second critical step is to embed fair process principles into workplace decision-making and resource allocation processes. The experience of such fair processes in workplaces should enable RNs in turn to care for individuals, families and communities in a respectful and dignified manner.
Acknowledgements This study, based on the first author’s thesis research, was funded by a grant to the second author from the Social Sciences and Humanities Research Council of Canada. Earlier findings were presented at the International Conference on Violence in the Health Sector, Vancouver BC, October 2012. We thank the health authority, nursing managers and registered nurses who participated in the pilot and main studies.
Ethical approval The study was approved by institutional review boards at two universities and the host hospital. Indication of participation consent was provided by completing the survey. All identifying information was stripped prior to entry into the survey database for anonymity. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1106–1114
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