Running head: BULLYING IN NURSING: DOES GENDER MATTER?

Bullying in Nursing: Does Gender Matter? NUR350/VL2/Dr. Ford August 5, 2011 By Dawn Johnson, Joan Kronlein, Jennifer Smith and Erin Tomlinson-Brower

(Comment from Dr. Ford): Excellent paper well written and an enjoyable read. Introduction: meets to exceeds expectations Literature review: meets to exceeds expectations Analysis of the evidence: exceeds expectations Application of evidence: meets to exceeds expectations Summary statements: meets to exceeds expectations Format: exceeds expectations Score: 28/30

BULLYING IN NURSING: DOES GENDER MATTER? Bullying in Nursing: Does Gender Matter?

Bullying in the nursing profession is a problem with a long-standing history and one that has been researched by many disciplines. The basis for this review is interest in the prevalence of bullying and whether it is varied between male and female nurses in the workplace. The PICO (Patient Population, Intervention of Interest, Comparison, and Outcome) question is: What is the difference in bullying between male and female nurses in the acute care setting? Four articles are presented to support our PICO question. The goals of our literature search are to determine implications for gender staffing ratios and implications for gender specific bullying educational programs. A literature review, analysis, and discussion of applications are included and show benefit to nursing practice. The four articles indicate a common thread that bullying is prevalent in nursing and bears amendment. Although no significant evidence was found to distinguish either gender as a dominant figure of bullying in nursing, there are fewer male nurses to study which may have some impact on results. All of the articles support education for prevention of this phenomenon in nursing and several offered initiatives to improve the incidences of bullying in nursing. These articles shed light on differences of bullying between genders and help bring attention to areas of need. As the articles indicate, by providing better education and prevention strategies it may be possible to achieve a less hostile work environment and overcome the oppression faced that may cause bullying. Literature Review Our focus was to search for scholarly articles aimed at answering our PICO question: What are the differences in bullying between males and females in the acute care setting? Of the ten articles chosen, six were rejected for content primarily because the articles did not include gender as a mitigating factor, however one article was rejected for age. The articles rejected

BULLYING IN NURSING: DOES GENDER MATTER?

were Erickson, and Ritter (2001), Center for American Nurses (2008), Valentine, P. (1995), Lou, J., Yu, H., Hsu, H., & Dai, H. (2007), Farrell G., Bobrowski C., & Bobrowski P. (2006), and Duddle M. & Boughton M. (2007). The articles were accessed through a universitys online library database. The articles used for this literature review are: Farrell, (2001), Bray, (2001), Ortega, A., Hgh, A., Pejtersen, J., & Olsen, O. (2009), and Speedy (2006). Farrell (2001) wrote, From tall poppies to squashed weeds*: Why dont nurses pull together more? This article explored a variety of bullying in the workplace including, but not limited to, the following: disenfranchising work practices, generational and hierarchical abuse, clique formation, low self-esteem, aggression breeds aggression, actor-observer effects, and the response of nurse managers and power relations between men and women (Farrell, 2001, pp. 28-30). This article concentrated on three levels of nursing conflict a macrolevel, mesolevel and microlevel. The macrolevel examined the dismissal of individual incidents and focused on nursing in relationship to medicine along with other dominant groups. Nurses felt alienated and powerless over their working conditions. This frustration was exhibited as conflict among the ranks (Farrell, 2001). The mesolevel examined the organizational structure, including workplace practices (Farrell, 2001). Nurses frequently accepted work practices that disempower and impede progress towards change and more productive working conditions (Farrell, 2001, p. 31). In addition, there are generational and hierarchical (Farrell, 2001, p.31) hurdles to cross. This could cause ambivalence and inferiority (Farrell, 2001, p.31) regarding their work which could result in an absence of solidarity among nurses (Farrell, 2001, p. 31). The micro level examined the interactional nature of interpersonal conflict (Farrell, 2001, p. 31). This described the interaction between people and asserted, when one person acted

BULLYING IN NURSING: DOES GENDER MATTER? with aggression [, it is] on account of [their] nasty personality (Farrell, 2001, p.31) and if we

react with aggression in return it is because of circumstance (Farrell, 2001, p.31). We attribute our own bad behavior to the situation that we find ourselves in and place blame on others (Farrell, 2001). This author admitted that bullying was not unique to nursing or females. The focus was on the underlying feminist views that could have been the underlying cause of bullying. Solutions to prevent bullying in the workplace were still a responsibility that all nurses had. Feminist perspectives and oppression gave insight to the interpersonal conflict among female nurses; however, if the focus was on the oppressive theory there could be missed opportunities. If some focus was placed on other aspects such as relationships with dominant groups, workplace practices and the interactional nature of personal conflict perhaps advancements could be made. Nurses must take the debate beyond the oppression theory and look at the issues through a different lens (Farrell, 2001). This article was significant to our research in that it was aimed at understanding the underlying conditions that contribute to gender bullying among nurses. Bray (2001) wrote the article, Bullying Nurses at Work: Theorizing a Gendered Experience. The author suggested that within hospitals there were strong masculine attitudes among workers. This contributed to bullying of staff. Bray stated that hostile people who are employed in a masculinized organization, like hospitals, become hysterical bullies in protest against their gendered confinement (Bray, 2001, p. 23). The theory asserted hospitals had masculine attitudes. The female workers took on the masculine attribute themselves and opposed it in other female workers (Bray, 2001). This would increase the prevalence and perception of bullying. Bray stated the establishment of anti-bullying practices in nursing means first

BULLYING IN NURSING: DOES GENDER MATTER?

acknowledging femininity and gender in the workplace, and then moving toward a one-gendered or genderless model of workplace relations (Bray, 2001, p. 28). This article contributed to our PICO because it looked at the gender difference between male and female nurses and recognized that females were taking traditional masculine attitudes which contributed to the hostile workplace. Ortega, Hgh, Pejtersen, & Olsen (2009) wrote, Prevalence of workplace bullying and risk groups: a representative population study. The study was conducted among the Danish population. The results indicated that female dominated occupations (Ortega, Hgh, Pejtersen, and Olsen, 2009, p.417) or people working with clients/patients (Ortega, et al, p.417) reported higher prevalence of bullying, but no significant gender or age differences were found (Ortega, et al, p. 417). The author also concluded that future gender studies were indicated. The article contributed to our PICO by recognizing bullying was higher in female dominated occupations, like nursing. Speedy (2006) authored, Workplace violence: the dark side of organisational [sig] life. The paper was an exploration of dynamics of bullying in the workplace. The main focus of the paper was on two types of bullying; aggressive, which was individual, and mobbing, which was considered a group behavior. The paper recognized nursing as a profession primarily dominated by women which could be a contributing underlying factor for bullying among nurses. Aggressive behavior was described as persistent criticism and personal abuseboth in public and in privatewhich humiliates and demeans the individual, gradually eroding their sense of self it is designed to undermine a persons ability and convince them that are no longer good at anything (Speedy, 2006, para. 5) The behavior was most commonly recognized in those persons placed and perceived to be in higher power. The author also went on to explore the gender

BULLYING IN NURSING: DOES GENDER MATTER? disparities in bullying. The author found females were more likely to bully other females versus their male counterparts. The author reported that 84% of the time females target other females

(Speedy, para. 32). The article aided our PICO in that it recognized that female nurses were more likely to bully other female workers versus their male co-workers. Article Analysis

Much information has been presented on bullying in literature; however information on differences in bullying between genders in the nursing profession is limited. An analysis of the articles chosen for our literature review follow a historical/qualitative perspective, an extensive literature review, a quantitative study, and theorized remedies for bullying. Contained within the articles are comparisons of female and male bullying (also referred to as conflict) and implications for gender specific bullying prevention educational programs. The first article reviewed was Bullying Nurses at Work: Theorizing a Gendered Experience (Bray, 2001). This sentinel qualitative study, based on psychoanalytical theory, discussed bullying in a masculine workplace and how gender may have affected hostility and reaction to others. Women bully in hostile connected ways, and men bully in hostile separation (Bray, p.26). Strength of the article was the use of nurse interviews and their experiences being bullied from both men and women. Additionally, the extensive literature review with psychoanalytical theory to explain bullying and gender difference was another strength. A weakness was the limited number of subjects interviewed. The age of the literature used for the authors literature review was another weakness. Research was presented from the late 1990s. The author concluded by agreeing with other authors that establishment of anti-bullying practices in nursing means first acknowledging femininity and gender in the workplace, and

BULLYING IN NURSING: DOES GENDER MATTER? moving toward a one-gendered or genderless model of workplace relations(Bray, 2001, p. 27), and education about bullying..should attend to gender difference (Bray, 2001, p. 27). The second article reviewed was Workplace Violence: The Dark Side of Organisational[sig] Life (Speedy, 2006). In this selective review of the literature, [the author has] drawn on the disciplines of nursing, management, psychology and organizational culture (Speedy, 2006, para.1). The author also examines whether there are gender issues (Speedy, para. 1) with workplace violence (bullying). She acknowledged nursing as a female dominated profession, and the need to examine the gender issue. The author found; 50% of bullies are female; female bullies target other females 84% of the time; male bullies target females 69% of the time; females are the majority of targets in the workplace; the vast majority of bullies (81%) are bosses (Speedy, para. 32). The author agreed that males and females are equally responsible for bullying behaviors (Speedy, para. 32). Males and females bully in different ways. Females are more subtle and

devious; males are more physically aggressive and action-oriented (Speedy, para. 41). Strengths of this article are the extensive literature review and the information is relative to all nursing areas where bullying takes place. A weakness is in the lack of quantitative evidence. The percentages listed are the only descriptive statistics used by the author. The third article reviewed, titled Prevalence of workplace bullying and risk groups: a representative population study, was a quantitative study by Ortega, Hgh, Pejtersen, and Olsen (2009), of bullying in the workplace, not nursing alone. The study was based on a large random sampling of the Danish working population. The authors tested multiple occupations, including health care. The study was well done. The chi-square test was used; the significance level was 5% (Ortega, Hgh, Pejtersen, and Olsen, 2009, p. 421). The null hypothesis test was explained,

BULLYING IN NURSING: DOES GENDER MATTER? and tested, as well as the key term of bullying, (both incidence and prevalence) and how each term was measured. No nursing theory was used due to the non-nursing specific nature of the study. An extensive literature review was completed, following a logical progression according to the aims (Ortega, et al., p. 419) of the study. The authors combated bias, by both mailing reminders and by telephoning (Ortega, et al., p. 419). The rights of the Danish citizens were protected by being allowed to opt out of the survey; however, no mention of confidentiality of the study participants information was included. This study showed no significant gender (P=0.11) [higher P-value means less correlation between gender and bullying] differences in the prevalence of bullying (Ortega, et al., 2009, p. 421). The strength is in the descriptive and

inferential statistics used in this study. The weakness is that it was not based in nursing theory, or on bullying in the nursing work environment. This is a well done study with implications for nursing and the general population. An analysis of From Tall Poppies to Squashed Weeds: Why Dont Nurses Pull Together More (Farrell, 2001) finds gender dynamics between nurses within a female dominated profession. Historically, nursing is seen as an oppressed discipline and suggests that intrastaff conflict in nursing is characteristic of their oppressed status (Farrell, 2001, p.27). The author follows three theoretical levels to explain staff conflict. The author contends horizontal violence is not a feature of oppressed groups alone; doctors eat their young too. Nor is it confined to female nurses; Men in nursing also feel oppressed to[o] (Farrell, 2001, p. 32). The author admits to oppression, but the ultimate responsibility for change lies with the individual nurse. The strengths of the article are again the extensive literature review, and the ease of reading and understanding the material presented. The author presents solutions that all nurses, both male and

BULLYING IN NURSING: DOES GENDER MATTER? female, can implement. Weaknesses are the lack of statistical evidence, and few references to gender differences. The evidence presented by our four articles results in preliminary findings. A more complete review of the literature including quantitative, and quality qualitative studies, grounded in nursing theory, are required to show the best evidence for future studies. Application of Evidence Bullying is all over the news today, particularly cyber bullying and school yard bullying. Work place bullying does not seem to be an issue if we are to believe the lack of coverage.

However, workplace bullying happens far more than thought, particularly in a female dominated profession such as nursing. The review of the articles resulted in the same basic conclusion, bullying is a form of aggressive behavior to strip power from the bullied nurse and puts it in the hands of the aggressor. The purpose of our literature review was to determine if there were bullying differences related to gender in the workplace. While gender does make a difference in the workplace it is apparent from the studies that there is no gender difference in bullying, but rather gender differences at work is the inherent imbalance in power relations between men and women (oppression) (Farrell, 2001, p. 27). The article further explains traditionally men have exercised power over women, thereby placing women in inferior and vulnerable positions relative to men (Farrell, 2001, p. 27). However, it is noted that while historically oppression may be an issue that needs solving, workplace bullying in nursing needs to be addressed by nurses themselves. Specifically, the practice of nursing itself, including the role of the individual nurse and that of nurse managers should be major foci (Farrell, 2001, p. 32). Education is paramount, beginning with upper level management enforcing a zero tolerance policy with regards to workplace bullying (Speedy, 2006, p 239). Education is also needed

BULLYING IN NURSING: DOES GENDER MATTER? regarding what workplace bullying is and the ramifications on the nursing unit. Lower quality

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patient care, lower productivity and higher turnover can be a direct result of workplace bullying on the nursing unit. Considering the potential consequences of bullying on the nursing unit, hospitals need to provide the gendered education necessary and put policies in place that send a clear message that this behavior will not be tolerated! Summary Eradication of bullying in nursing is a work in progress and in reviewing these articles, it is obvious there is much to be done before this can happen. The articles reviewed have addressed the PICO question in differing ways; however, no significant findings have allowed determination of the gender ratio in bullying among nurses. Historically men have had power over women, this places women in a vulnerable and inferior position (Farrell, 2001, p.27) was a central idea to our goal in finding gender ratio implications, but results did not associate nurses specifically in this way. The study by Ortega, Hgh, Pejtersen, and Olsen (2009) showed no significant gender differences in the prevalence of bullying (Ortega, et al., p. 421). Our goal, to find implications for gender specific bullying educational programs focused on prevention, was more successful in this review. One article called for zero tolerance policies to prevent and discourage future bullying and for managers to educate nurses about what could be considered bullying behaviors (Speedy, 2006). Another article suggested establishment of anti-bullying practices in nursing means first acknowledging femininity and gender in the workplace, and then moving toward a one-gendered or genderless model of workplace relations (Bray, 2001). These helped indicate need for gendered education, as suspected. The results are inconclusive in this literature review, as implications for gender staffing ratios were not found. Differences in male and female bullying were found, but not clarified with certainty as

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to whether one gender is more bullying. The information found may be useful for future review into bullying trends, but further study is warranted.

BULLYING IN NURSING: DOES GENDER MATTER? References Bray, C. (2001). Bullying nurses at work: theorizing a gendered experience. Contemporary

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Nurse 10, 21-29. Retrieved via interlibrary loan, through Ferris State Universitys online library, from the University of Missouri-St. Louis. Center for American Nurses. (2008). Lateral Violence and Bullying in the Workplace. Retrieved from Pubmed through Ferris State Universitys online library database. Duddle M. & Boughton M. (2007). Intraprofessional relations in nursing. Journal of Advanced Nursing 59(1), 2937. Erickson, R. & Ritter, C. (2001). Emotional Labor, Burnout, and Inauthenticity: Does Gender Matter? Social Psychology Quarterly, (64)2, 146-163. Retrieved from JSTOR through Ferris State Universitys online library database. Farrell, G. ( 2001). From tall poppies to squashed weeds: why dont nurses pull together more? Journal of Advanced Nursing. (35)1, 26-33. Farrell G., Bobrowski C., & Bobrowski P. (2006). Scoping workplace aggression in nursing: findings from an Australian study. Journal of Advanced Nursing 55(6), 778787. Lou, J., Yu, H., Hsu, H., & Dai, H. (2007). A study of role stress, organizational commitment and intention to quit among male nurses in southern Taiwan. Journal of Advanced Nursing, (15)1, 43-54. Retrieved via interlibrary loan from Ferris State Universitys online library database. Ortega, A., Hgh, A., Pejtersen, J., & Olsen, O. (2009 ). Prevalence of workplace bullying and risk groups: a representative population study. International Archives of Occupational and Environmental Health 82, 417426. doi 10.1007/s00420-008-0339-8. Retrieved via Pubmed from Ferris State Universitys online library database.

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Speedy, S. (2006). Workplace violence: the dark side of organizational life. Contemporary Nurse 21.2, 239. Academic OneFile at http://0go.galegroup.com.libcat.ferris.edu/ps/i.do?&id=GALE%7CA158527218&v=2.1&u=lom _ferrissu&it=r&p=AONE&sw=w. GALE|A158527218. Valentine, P. (1995). Management of conflict: do women/nurses handle it differently? Journal of Advanced Nursing, 22, 142-149. Received from Oakland University via interlibrary loan through Ferris State Universitys online library database.