But workplace and incivility is less common in hospitals where line managers show ‘authentic leadership’ behaviours, reported researcher Professor Stephen Teo at this month’s Australian and New Zealand Academy of Management Conference.
He reported that 59 per cent of the 230 nurses surveyed recounted witnessing bullying in their workplace, while 48 per cent reported being a target. Of the bullying targets, 39 per cent experienced bullying now and then, while 12 per cent went through the ordeal several times a week.
Teo, of Cowan University’s Centre for Work and Organisational Performance, said the high level of bullying partly reflected the healthcare sector where people were often promoted primarily based on their clinical skills and the soft skills, such as managing people and relationships, were considered secondary.
“The pressure of the medical field can expose weaknesses, so a manager may react abruptly and be snappy, and if that isn’t addressed, it can become normal,” said Teo. “This has a trickle-down effect on how those around them act.”
His research considered the impact of civility – which included not just traditional workplace bullying but also behaviours like rudeness, creating feelings of exclusion, unfair work distribution and negative body language or tone.
He said nurses that witnessed or experienced incivility were 52 per cent more likely to report psychological stress, which had been linked to increased health problems, turnover and decreased efficiency.
But in workplaces were line managers, like charge nurse mangers, demonstrated ‘authentic leadership’ characteristics like honesty than nurses’ perception of incivility was 37.5 per cent lower, which in turn reduced stress.
“Authentic leaders model positive social behaviours while being self-aware and open and honest,” Teo said. “They embody the organisation’s professed values, even if they aren’t perfect.”
His research also found that nurses who felt they and their organisation had shared values, experienced lower levels of workplace incivility and psychological stress.
“Overall, our research suggests healthcare organisations need to put more emphasis on training to provide line managers with skills and tools to navigate the human side of work,” Teo said.
BULLYING RESOURCES
He was responding to the Association of Salaried Medical Specialists (ASMS) survey published today which found a third of senior doctors and dentists had been bullied at work, and two-thirds had witnessed others being bullied – mostly by fellow doctors. The survey findings were presented to the ASMS Annual Conference in Wellington today and showed that much of the bullying was between medical colleagues with the most common bullying perpetrators being fellow senior doctors (52.5%), followed by non-clinical managers (31.8%) and clinical leaders (24.9%). (See full survey story at Health Central)
Musa said the NZNO Employment Survey and the NZNO journal Kai Taiki had repeatedly found that bullying had a huge effect on the nurse involved, and their colleagues, and could get to the point nurses leave for other jobs, go overseas or leave the profession altogether. He said he backed the Association of Salaried Medical Specialists’ call to bring the matter to the attention of district health board leaders and boards.
The report, Bullying in the New Zealand senior medical workforce: prevalence, correlates and consequences, is based on a survey of ASMS members in June 2017 with a nearly 41 per cent response rate.
“NZNO leadership will talk with Ian Powell (ASMS executive director) shortly as nurses have this issue too and we know that nurses are leaving the workforce for a different career because of it. This is the opposite of what this country needs, let alone our patients,” Memo Musa said.
“We know that in an underfunded health system the internal stress and pressure takes its toll. When nurses and doctors and other professionals are thin on the ground and working double shifts, the working environment is not good, healthy or staff do not feel safe to speak up against bullying.
He said its report into short staffing at Counties Manukau DHB clearly showed that when there is understaffing that discomfort levels go up in the workplace with one nurse being yelled at if the requested help. Musa said an article in the June edition of Kai Tiaki about a nurse who walked away from her job –after management failed to stop the bullying that went for two years by a charge nurse gained a ‘huge amount’ of Facebook comment from nurses sharing similar stories. “This is outrageous considering nurses are highly regarded by society yet too often treated badly in their employment situation.”
“We know that Lakes DHB, Auckland DHB and Capital and Coast DHB for example are proactively tackling this problem and it is commendable,” said Musa. “But there is a long way to go for the entire staff management system to operate in a way that protects all staff and has the right management and skill mix to avoid bullying and to indeed address it.”
Behaviour described in the ASMS report ranged from violence, threats and intimidation through to humiliation, persistent criticism, allegations, gossip, exclusion and excessive monitoring of work.
Key ASMS findings included:
ASMS Executive Director Ian Powell said the survey findings were very concerning and the union would be discussing them further with DHB chief executives and senior managers. Copies of the report had been sent to all DHB Chief Executives, as well as new Minister of Health, Dr David Clark.
Bullying Resources
Natalia D’Souza, a Massey PhD student, held in-depth interviews with eight nurses who reported experiencing cyberbullying – harassment or other unwanted bullying behaviour via electronic means from texts to social media posts – from both within and outside their workplace. As a result, she has made a number of recommendations for nurse employers, including incorporating cyber ill-treatment and bullying into existing bullying guidelines, and having clear mechanisms for reporting and investigating digital evidence of bullying.
D’Souza said while five of the eight nurses she spoke to experienced cyberbullying from within their organisation – from colleagues or workplace superiors – three reported cases of bullying were from outside the organisation, including in two cases the parents of patients and, in the third case, the defamatory bullying of a nurse academic.
She said the research showed that, particularly in small communities, public incidents of cyberbullying – via social media or public blogs – had the potential to damage not only the reputation of the nurse target but also the organisations they work for.
The cases of external bullying included defamatory Facebook posts involving false sexual allegations made by the mother of a patient against the nurse victim. Another patient’s mother had bullied a nurse by leaving hostile and aggressive voicemail messages and sending hostile texts. The third external case involved a defamatory and anonymous blog post that was suspected to have been made by the student of a nurse academic. D’Souza said in least two of these cases, cyberbullying not only impacted upon the targeted individuals, “but also created negative publicity for the organisations involved, with the potential to hamper the provision of health services, particularly within small communities”.
She said bullying behaviour via social media or blogs or email chains not only increased the audience but were also used to damage social and professional networks and isolate the bullying target. “In one case of anonymous cyberbullying, this not only increased the threat level for the target, but also prevented effective resolution by the organisation.”
D’Souza said her study participants also indicated that two key features of cyberbullying were generally perceived to be more harmful: cyberbullying that resulted in a blurring of home/work boundaries and/or cyberbullying that was played out in a relatively public domain.
She said unlike face-to-face encounters, cyberbullying can persist beyond the physical workplace and working hours as digital devices provide continued access to targets.
“In this way, aggressive or unwanted cyber behaviours are not only repeated, but can transcend traditional safety strategies such as the use of security staff, being removed from the premises, and trespass notices,” said D’Souza. “More importantly, at present there is little that organisations can do to successfully resolve such incidents, as workplace cyberbullying currently remains beyond the scope of current organisational, industry, and national-level policy. In fact, many cases in this study often lacked a clear resolution to the cyberbullying and targets were often left feeling uncertain and anxious about future incidents.”
D’Souza said for most of the eight bullying targets the cyberbullying was part of a broader pattern of bullying behaviour within the workplace, including “unwarranted disciplinary and excessive performance management”, undermining comments, being ignored or excluded, plus offensive and aggressive emails and texts.
All eight participants indicated that other nurses within their organisation had also been cyberbullied. Many bullying targets had not reported the cyberbullying, said D’Souza, as they believed they could or should deal with it on their own, but only in one case had the cyberbullying been successfully resolved by the target’s own efforts. In a couple of cases the targets believed the ‘bully’ was supported by upper management and this had discouraged them from reporting the bullying.
A few participants had also noted that underfunding in healthcare meant that nurses were being blamed for system-level issues, such as shortages of staff, increased workloads, time constraints and insufficient resources. “Such environments largely support the occurrence and tolerance of workplace bullying.”
D’Souza concluded that cyberbullying in nursing is a “growing workplace psychosocial safety hazard that needs to be addressed immediately”.
Cyberbullying involves unwanted aggressive behaviours that may harm, threaten, demoralise or embarrass the person on the receiving end. This can occur through a range of electronic media including text and instant messages, emails, social media, blogs and public web forums. Workplace Cyberbullying can occur outside of the workplace and after hours.
*Resources section added November 9 2017
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President of the college Professor Tony Lawler said bullying, discrimination and sexual harassment were “distressingly common in the emergency care environment in Australia and New Zealand”.
The behaviour reported in the survey posed a risk to health, safety and professional well-being and also had a negative impact on the workplace, training environment and provision of care, he said.
“ACEM seeks to promote the highest possible professional standards for emergency physicians. These principles are explicit in college policy and standards for accreditation for training in emergency medicine. These findings are not consistent with whom we believe ourselves to be, and we must respond to that,” he said.
“We recognise that quality health care outcomes are dependent on high functioning teams across the hospital setting, and we are not doing the profession of emergency medicine or our patients any favours by conducting ourselves in this way.”
The survey carried out in April and May this year was part of a working group formed last year to explore the workplace and training culture in response to increased scrutiny of the medical workforce culture in 2015.
Lawler said the organisation would take immediate action to address the findings by consulting with members to prepare and publish an action plan by the end of November.
“The college is committed to its role of upholding the highest possible professional standards in emergency medicine. We have taken the initiative to understand the extent of these behaviours among members and trainee,” he said.
“We owe a duty to our members, fellows and trainees to do what we can to ensure emergency medicine is practised in a respectful and inclusive environment, and will use this experience to listen to and engage with our members to bring about meaningful cultural change and address the problems caused by some members of our profession.
“As healthcare workers on the front line and directly in the public eye, emergency physicians need to take a leadership position and champion and model the high standards of behaviour we expect of others.”
]]>Ashleigh Smith (19) received her Queen’s Young leaders Award in Buckingham Palace late last week for her work with the Sticks ‘n’ Stones group she helped found to empower young people to recognise and stand up to bullying.
In a video posting on the Stick ‘n’ Stones Facebook page (made just before flying back to New Zealand) she said it was “just so crazy” that the day before she was in Buckingham Palace receiving an award from the Queen.
She said the message she wanted to share with the group’s followers was that you never knew where your passions and hard work could end up taking you.
“I’m just a small town country girl. But I’m a small town country girl who had a passion and wanted to do something about it.”
“And I believe that every single young person in this country is passionate about something.”
“No matter how hard it gets – keep going,” she shared. “Follow your passions. Do your best that you can to achieve and you never know you where you will end up.”
As a Queen’s Young Leader she was one of 60 young people selected for the awards programme from around the Commonwealth. The programme offers a year-long package of training, mentoring and networking offered through Cambridge University including the one week residential programme at Cambridge she completed beforeshe and her fellow young leaders received their awards personally from the Queen at a ceremony on June 29.
Five years ago three of Ashleigh’s schoolmates at Maniototo Area School took their own lives within eight months of each other leaving her not knowing what to do with herself. When government funding became available for an anti-bullying campaign Ashleigh and student leaders from five other Central Otago schools grabbed the opportunity and founded ‘Sticks n Stones’. Under the scheme student ambassadors are trained and given the skills to help other young people, especially with online issues, or helping them find the right support network.
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Five years ago three of Ashleigh’s schoolmates at Maniototo Area School took their own lives within eight months of each other leaving her not knowing what to do with herself.
“It was a hideous time. I was 13, and trying to comprehend why someone would make that decision. I was angry and sad all at the same time.”
When government funding became available for an anti-bullying campaign Ashleight and student leaders from five other Central Otago schools grabbed the opportunity and founded ‘Sticks n Stones’. Under the scheme student ambassadors are trained and given the skills to help other young people, especially with online issues, or helping them find the right support network.
“There was such a generation gap between advice versus how youths were living their lives online.”
The group also plays an advocacy role as Ashleight points out a lot of decisions are made about youth without consulting youth.
“A lot of decisions are being made about youth without consulting them. She said the group was now being approached for its views on policies like the ‘Harmful Digital Communications Bill’.
The London trip is not Ashleigh’s first time on the national and international stage as she has spoken at a Dublin conference on bullying. As a Queen’s Young Leader she is one of 60 young people selected for the awards programme from around the Commonwealth. The programme offers a year-long package of training, mentoring and networking offered through Cambridge University including a one week residential programme at Cambridge and receiving their award personally from the Queen at a ceremony on June 29.
]]>The new Health and Safety at Work Act puts the onus on employers to eliminate or minimise risks to their workers’ health and safety – including their mental health.
Studies both here and overseas show that caring for others – who are often at their most vulnerable – in today’s fast-paced, high acuity, high workload health sector can come at a cost to the mental health and wellbeing of the carers.
It can lead to unhealthy stress levels, fatigue, emotional exhaustion, cynicism, compassion fatigue, moral distress and burnout. It can also be a trigger for anxiety and depression disorders.
But while nurses may talk about stress or feeling emotionally drained at the end of a day, it appears that few are likely to share that they have a mental health disorder like anxiety and depression.
Nursing blogger Barbara Docherty last year described depression as nurses’ “best kept secret” in a blog that went viral, attracted many social media comments and led to nurses taking the opportunity to confidentially share their stories.
It should not be a surprise that nurses suffer depression and anxiety as the 2012–13 New Zealand Health Survey found that one in six New Zealand adults (16 per cent) had been diagnosed with common mental health disorders (including depression and anxiety) at some time in their lives, and one in five New Zealand women.
Literature reviews also indicate that mental health issues are more prevalent in nursing and the other health professions than they are in the general population – probably because of the high stress and emotional demands of the work.
For example, a major review of the health and wellbeing of Britain’s NHS staff by Dr Steve Boorman released in 2009 found that sick leave taken by NHS staff was 50 per cent higher than in the private sector. About £1.3 billion of the £1.7 billion estimated annual cost could be attributed to mental health problems.
A recent study of nearly 3,500 Chinese nurses found an estimated 38 per cent had depressive symptoms. A 2012 study of 1,171 American nurses funded by the Robert Wood Johnson Foundation found that nurses had twice the rate of depressive symptoms of the general public (18 per cent, compared with 9.4 per cent).
An Australian retrospective study found elevated rates of suicide amongst nurses and female doctors, compared with other occupations, with one explanation raised being greater exposure to work-related stressors.
These are stark statistics. What are the possible reasons behind them and how could the mental health and wellbeing of nurses be better supported?
“I think we should work with the assumption that all nurses at some time are going to struggle because of the emotional work we do,” believes Dr Jacquie Kidd, a researcher in the field of nursing and depression.
Kidd’s PhD research drew on the experiences of 18 Kiwi nurses experiencing mental illness while practising. She believes that if both the profession and sector acknowledged that nursing is a vulnerable workforce under high emotional stress they would be more open to providing the early intervention and support required.
“I think we would be much healthier,” says Kidd, who is also a Waikato-based senior lecturer for the University of Auckland and teaches and coordinates a mental health new graduate programme.
She says programme leaders tell nurses starting out in their first mental health jobs that after a honeymoon period all of them will hit the wall and think they are hopeless nurses and wish they’d never chosen mental health nursing as a career. But the programme leaders also reassure them that when that happens they will be supported with whatever help they need, and that they will come through it.
Kidd thinks this type of approach should be extended to nurses throughout their careers because not only does the public place “huge” expectations on nursing as a caring profession, but the profession also puts high expectations on itself.
The fear of letting their colleagues or ‘the badge’ down may be one reason few nurses are ready to speak up when they are struggling, believes Kidd.
“In the beginning, depression and anxiety can feel like you are doing something wrong … you feel you’re not quite as good or as fast as everybody else and you are struggling to cope with patients and families that your colleagues just seem to be sailing through with.”
Kidd says by covering up and putting on a brave front of ‘coping’, struggling nurses can miss the early warning signs and the opportunity for early interventions to prevent mental health issues affecting their work. Pushed nursing colleagues may also struggle to feel compassion for a struggling colleague because they are worried about the impacts on their own workloads and mental health if they offer support and help.
Dr Stacey Wilson, a mental health nurse with a research interest in emotional competency, says there is also a sense that nurses should know better, as depression is somehow seen as “quite self-absorbing or selfish” and “nurses aren’t really allowed to be like that”.
Wilson acknowledges the irony that as a profession nurses encourage clients to seek help for mental health or addiction issues and are positive about mental health recovery. But personally it may be a different story because there is still a stigma attached to disclosing mental health issues as a nurse.
“I don’t know many nurses who would say that they are off on leave because of a mental health or a drug or alcohol issue,” says Wilson. “Some might say they are on stress leave.”
Both Kidd and Wilson believe that contributing to nurses’ stress and distress is the disjoint between what draws many nurses to the profession in the first place and the reality of the modern workplace.
“My impression is that what makes us resilient is the time we spend engaging with patients and families – because that’s where we get the sense we are doing a good job,” says Kidd. But working at full capacity can leave nurses little time to foster the relationships that give them energy.
“I think we are in an ever-decreasing circle – we’ve got less and less soul-feeding happening and yet we are giving more and more.”
Wilson says constant change in the health sector is another factor, along with nurses trying to juggle the demands of work with the pressure to do postgraduate work, look after families and attempt a semblance of work/life balance.
So what steps could be taken to better care for the carers?
“If we expect the healthcare workforce to care for patients, we need to care for the workforce.”
This quote from the National Patient Safety Foundation’s Lucian Leape Institute is one of the philosophical drivers for nurse Janice Riegen’s work.
The clinical nurse specialist in occupational health and safety is passionate about the urgent need to create healthy workplaces in the health sector, including reducing the risk factors for anxiety and depression.
“What the literature is telling us is that anxiety and depression are going to be the leading cause of workplace absence for everybody in the next five years – not just in healthcare,” says Riegen. Contributing factors to this include psychosocial risks which Riegen says are becoming one of the biggest health and safety challenges in the modern day workplace worldwide.
Riegen’s master’s research was into what contributes to a healthy workplace and she has presented on the topic internationally. Waitemata District Health Board, who Riegen works for, has created a Healthy Workplace steering group – inclusive of the main unions. Last year the DHB’s board and senior management gave the go-ahead to a Healthy Workplaces Strategy for the organisation and its staff.
The three-year programme lists 15 actions ranging from developing an age-friendly working environment to offering mindfulness and wellbeing sessions, and from supporting best practice workload management to promoting good shiftwork and fatigue management practices.
Riegen says that any healthy workplace strategy needs to be holistic and look at all work aspects that can impact on staff health and wellbeing. “Because what the evidence tells us is that one-off things are no good.” The DHB have used the World Health Organisations ‘Healthy Workplace’ (2010) definition and action model as a basis for the work, along with New Zealand’s Te Whare Tapa Whā model.
So, for example, offering mindfulness and wellbeing sessions is good – but a strategy needs to permeate an organisation’s culture and address psychosocial risks as well.
Riegen says that doesn’t mean you shouldn’t do anything in the interim – she points out that Waitemata’s strategy has been five years in the making and is still a work in progress – but that the bigger picture should always be kept in mind.
Including that there is a very good business case for investing in healthy workplaces as having healthy staff – both physically and mentally – results in less absenteeism, ‘presenteeism’ and staff turnover and leads to greater productivity.
“Also in the last few years the research about the inextricable link between staff health and wellbeing and the safety and quality of the experiences and outcomes for the patients has nearly doubled,” says Riegen.
Safe staffing is definitely one part of a healthy workplace, Riegen says, and if you talk to nurses anywhere their main safety focus is on workload pressures. Excessive workload is a psychosocial risk (according to European Agency for Safety and Health at Work) that can contribute to mental health issues, along with a lack of involvement in decision-making and a lack of support from management or colleagues.
“I used to do bureau work and I could tell how healthy the workplace was straight away after walking in – just based on how I was greeted and welcomed.”
The nursing literature agrees that teamwork – and good managers who foster it – is a very important component of nurse wellbeing in the workplace.
For instance, the Magnet Hospital research, which distilled the common characteristics of hospitals able to attract and retain satisfied nurses during nurse shortages, found that these hospitals not only had adequate staffing, but also offered professional autonomy, participatory management styles, well-prepared leaders and teamwork.
Alison Ogier-Price, who leads the Working Well programme for the Mental Health Foundation and has been working for a number of DHBs to help develop wellness programmes, sees training and supporting managers as crucial
“I see teams that function so well,” she says, “and the heart of it is always that manager who gets it – someone who likes people and gives people a sense that they are participating in decisions that are happening around them.”
But sometimes charge nurse managers (CNMs) are in the role due to seniority or their clinical skills and don’t have the skills to run a team of people. Or they are scared to raise mental health concerns with staff because of uncertainty around what is okay to ask about and what is not. Sometimes managers themselves are affecting the mental wellbeing of their staff because of their communication styles and, on occasions, bullying behaviour.
“Sometimes bullying issues arise through lack of training – they don’t realise what they are doing,” says Ogier-Price. She says that is why it is important to invest in training managers to listen to what’s going on, acknowledge it and respond by using positive and communicative management styles. Training should include communication skills, conflict resolution and team-building skills to create cultures where teams work well together and feel free to raise issues of concern.
Kidd suggests that charge nurse managers may do well to have the ongoing support of HR, rather than HR stepping in when things go pear-shaped.
Riegen says the evidence indicates that line managers should also be trained in supporting staff at risk of mental health issues because if staff have trusting relationships with their managers then they will turn to these people first when they are struggling at work. But line managers, who can be the meat in the sandwich between staff and senior management, also need the skills and the tools to take care of themselves.
“It seems to me it doesn’t matter what position you are in the hierarchy of nursing – the level of stress and the potential for developing a mental health problem that is work-related is pretty high,” says Wilson, who provides professional supervision for nurses, from new graduates to charge nurses. “I don’t think because [managers] are at the top of the food chain that they are any more resilient to the work pressures – maybe they are even more vulnerable.”
Everyone who Nursing Review spoke to agreed that in an ideal world one-on-one professional supervision would be more widely available to help both managers and their nursing staff to critically reflect on their practices, plan their careers and work through some of the challenges facing them in their work.
Wilson says it could also help to defuse anger and conflict in a team if an issue could be resolved by confidential supervision rather than “spreading around like a virus” and infecting everybody.
So in the real world what can you do, as a nurse, to contribute to the mental wellbeing of yourself and your colleagues in a pressured work environment?
For a start, be kinder and more compassionate to yourself and be kind to your colleagues, who may be struggling around you.
“We’re a highly educated workforce that works in very difficult and challenging situations in some of the most dire times in people’s lives,” says Wilson. “We need a little reminding that nurses are valuable people and it is worth spending a little time being a little compassionate to yourself and working on your emotional competency so you are in good shape for work.”
Ogier-Price, who specialises in applying positive psychology to organisational wellbeing, agrees, saying that nurses generally don’t take good care of themselves and – strangely enough – don’t always have the information or skills to recognise when and how much support they need.
She has been offering wellbeing workshops in collaboration with the quake-challenged Canterbury DHB for the past three years, and after being called in to support other DHBs has come to believe that ‘care for the carers’ information is lacking in the health sector. In her role with the Mental Health Foundation she was commissioned to write a white paper for the Ministry of Health on the topic – something like a ‘working well’ guide for the health sector.
Ogier-Price says a health and wellbeing culture should permeate an entire organisation and include reducing the stigma of mental health illness so that people struggling with anxiety and depression feel more able to speak up.
In larger organisations this can include having access to EAP (Employee Assistance Programmes) that typically offer three free and confidential sessions with a counsellor or psychologist about personal and work issues that may be affecting workers’ productivity.
Kidd, for one, thinks that nurses could be making much more use of EAP. “Just having somebody who is paid to listen to you and talk about your woes … can really help to crystallise what you might need to do to help yourself feel better.”
Ogier-Price says organisations should also promote or offer programmes that help people to maintain and sustain their mental wellbeing.
Encouraging exercise is one example, as there is a growing body of evidence that physical exercise can be effective for people with mild to moderate depression. Programmes that can help people to relax, such as yoga, meditation or mindfulness, are also available, plus others that focus on the other important components of wellbeing, such as nutrition and sleep. Wellbeing workshops such as those offered at Canterbury DHB can teach nurses how to better care for themselves as carers.
Ogier-Price says an absolutely ‘core concept’ that she emphasises in her workshops is the need to build social networks at work, as this is where people spend so much of their lives. This includes creating a work environment where socialising can occur, such as a lunchroom, which she acknowledges can be challenging in busy wards with little private space. Finding a way for staff to get together regularly should be a priority, she says, even if it is just getting together for special morning teas once in a while.
After listening to nurses offload during wellbeing sessions, Ogier-Price is also interested in whether the idea of facilitated support groups, similar to those offered by Alcoholics Anonymous, could be helpful.
Another approach that Ogier-Price encourages in her workshops is for nurses to boost their wellbeing by “basically doing the stuff you enjoy doing”. She says that to avoid chronic stress nurses need to routinely and frequently de-stress during the working day.
“People need five minutes off every hour to de-stress so for the next hour they can function that much better.”
This may be as simple having a laugh or an enjoyable conversation. In a particularly busy day it may be just grabbing a minute to go into the corner and take some deep, calming breaths. In longer breaks it could be grabbing a chance to take a walk outside, knit or do a Sudoku puzzle – whatever helps them to relax.
Apart from stress management, Ogier-Price says other training programmes that could benefit nurses include assertiveness training and boundary setting to help them deal with both difficult patients and colleagues (see p.8 for some stress management tips).
Wilson and Kidd also believe that pre-entry and ongoing nurse education should acknowledge that nursing is emotionally draining work and help them to build the self-awareness and emotional competency skills needed to be resilient and care for themselves and others.
But it is not up to nurses alone to care for themselves – what is also needed is a health sector that cares for its carers. Creating a healthy workplace for carers – to paraphrase the World Health Organization’s healthy workplace motto – is the “smart thing, the legal thing and the right thing to do”.
Lifeline
24/7 helpline on 0800 543 354 or (09) 522 2999 within Auckland.
www.lifeline.org.nz
Depression Helpline
Free 24/7 advice from trained counsellors. Phone 0800 111 757 or txt 4202.
https://depression.org.nz
Depression.org.nz
Resources include a self-test for depression and the online journal tool.
https://depression.org.nz
Mental Health Foundation
Information on mental health conditions, the Five Ways to Wellbeing and the Working Well programme. www.mentalhealth.org.nz
MoodGYM training programme
Offers cognitive behaviour therapy (CBT) skills for preventing and coping with depression.
https://moodgym.anu.edu.au
Black Dog Institute
Information, advice and online tools for both individuals and health professionals on mood disorders like depression. www.blackdoginstitute.org.au
Worksafe
Guide to new Health and Safety at Work Act (2015) and other resources.
www.worksafe.govt.nz/worksafe
NHS Health and Wellbeing Final Report 2009
www.goo.gl/jn7826
Good Day at Work (UK)
Free online iResilience tool – test your resilience and get feedback.
www.robertsoncooper.com/gooddayatwork
Winter can be a challenging time to be nice on the ward. Demand for beds can go up and staff numbers go down as winter illnesses hit.
It is the second winter for Mikaela Shannon as nurse manager of inpatient services at Kenepuru Hospital, which is 18 months into a ‘Care with Dignity’ project that morphed from focusing on staff being kind to patients to nurses being kinder to each other.
Shannon says this winter, when wards are short-staffed and flag they need help, it may well be a team manager who arrives to work on the floor beside them.
“All my managers are in uniform now. They used to be in their own clothes. At the end of the day we are all nurses and we are slowly getting that culture that we are all there to help. And I too can make a bed and take a patient to a toilet.”
Shannon believes “absolutely” that if you want culture change you need to “get on the floor and role model it”.
And when she arrived nearly two years ago to take up the post of managing around 100 nurses and healthcare assistants in Kenepuru’s five inpatient wards, a culture change was being called for by Capital & Coast District Health Board’s head office. There was concern about some ‘unpleasant’ online patient feedback and a series of complaints to the Health and Disability Commissioner, says Shannon.
Working with the director of nursing’s office, it was decided to adapt the United Kingdom’s ‘Dignity in Care’ approach and the Royal College of Nursing’s related ‘Dignity: At the heart of everything we do’ campaign to form the basis of Kenepuru’s Care with Dignity programme, which was held last year and underwent an independent evaluation by Whitireia New Zealand.
Shannon says the campaign started simply with wearing name badges and taking a “Hello my name is” approach to communicating with patients. It then moved on to an education workshop looking at dignity, patients’ rights and ideas for improving patient care, which were supported by appointing ‘dignity advocates’ in each ward to highlight and champion putting the improvements into action.
The project focused on treating patients with dignity and respect but it got some staff questioning how respectful staff were of each other. And amongst the Whitireia evaluation report recommendations – including management providing the resources, time and environment to put the Care with Dignity philosophy into action – was a call for all healthcare workers themselves to “model a culture of care with dignity”.
“Over 18 months we probably had four or five events where people had not been very nice to each other … really harsh, ‘eat your own’ type stuff,” says Shannon.
Some events involved new graduate registered nurses or new enrolled nurse staff being snapped at when asking a question or for help, leaving them in tears.
The dignity training meant staff were ready to speak up about unkind behaviour, including one healthcare assistant reporting, “Yes, I’m under direction and delegation, but I don’t need to be shouted or screamed at.” “People can have a bad day,” says Shannon. “But they still need to communicate respectfully to each other.”
Some staff also expressed concern about patients having to hear the “silly banter” of staff being disrespectful to each, including the incoming shift’s nurses sniping about what the previous shift had left undone.
The result is that this year there is a follow-up pilot Care with Dignity project for fostering respect and dignity between nursing staff that got underway in April to build on the groundwork of last year’s patient-focused programme.
It’s early days yet but Shannon says things are changing and nearly 60 per cent of staff are on board, with feedback indicating that the dignity advocates, focus groups and ward teams are working on developing a ‘culture for caring’ and a zero tolerance for bullying-type behaviour (see sidebar).
All her senior team staff are trained and supported in conflict management, including giving staff feedback and assessing ward culture. Work has also been done with staff whose actions prompted the call for more kindness, including using a ‘coach and buddy’ system, role reversal discussions and peer mediation, plus making sure that staff have the appropriate professional language and strategies to use when things go wrong. They are also encouraged to come to meetings with not only problems but also possible solutions.
Shannon says she once had new grads and ENs coming to her in tears but now she believes that the former ‘I’m not helping you’ or ‘we’re not working as a team’ vibe is very much gone.
Shannon acknowledges that the stresses and strains of the modern health system also take their toll on a nurse’s capacity to be caring.
“Most people don’t come to work to be unprofessional – they come because they want to do a good job but they get stressed and snap or say the wrong thing.”
She believes what is helping is having the dignity advocacy groups where people can talk about some of the pressures and issues that make them act unprofessionally.
“It is not perfect yet by a long shot – don’t get me wrong.” But she feels Kenepuru is now on the right track.
Part of the move to “being nicer to each other” is Kenepuru’s new approach to rostered and rotating shifts. Shannon says the roster may have been a source of tension before but there is now a push towards a ‘self-rostering’ model with the aim of allocating shifts fairly and “looking after each other like a team”.
“It is no longer ‘my way or no way’. [For example] we had an awful lot of nurses who had had their families and worked mornings but their families had now left home and they were still working mornings – that kind of thing.”
Roster discussions start at ward meetings and while some people request shifts online there is still a paper roster in the staffroom where people can negotiate and swap shifts before the roster is finalised and published.
Shannon says it can be hard work role-modelling a culture change and she needs to be mindful that she may not always get it right.
But while it may take longer to get some staff on board with the new philosophy than others, she says a Dignity Week in March was a turning point for her as positive things happened on wards not just because she or her senior managers were around or had initiated them.
“We now have a platform where dignity is business as usual,” says Shannon. And, “touch wood”, after 22 months in the job, staff turnover is very low and she has not had to deal with any serious patient complaints. “Which, for me, says volumes.”
ENCOURAGE
NOT OKAY
Behaviour and values guidelines developed by Kenepuru nurses to foster respect and dignity between nursing staff.
The Massey University management lecturer interviewed 34 bullied hospital nurses for her PhD thesis and was shocked by the impact bullying can have. The majority of nurses had reported the bullying but she spoke to only one nurse whose complaint had been successfully resolved. Less than a handful had managed to stop or control the bullying by directly addressing the bully themselves while the remaining interviewees were either still being bullied or had resorted to changing jobs (see full research findings in sidebar below).
“The unfortunate reality is that at the moment targets (bullying victims) leaving is the best chance of getting away from workplace bullying,” says Blackwood.
Blackwood’s research followed on from a 2009 workplace bullying study which found high levels of workplace stress (75%) and workplace bullying (18%) in the New Zealand health and education sectors.
A number of health sector respondents in that research noted that bullying was a “big problem” within nursing – specifically ‘manager-to-nurse’ and ‘consultant/doctor-to-nurse’ but also ‘peer-to-peer’ bullying.
The focus of workplace bullying research has moved on from looking at the personality traits to seeing bullying as a product of the work environment and placing the onus on organisations – like health sector employers – to do something about it.
“Bullying wouldn’t be as rife in health care as it is right now if there wasn’t a culture of tolerance for bullying,” says Blackwood. “If there wasn’t a culture of nurses being expected to harden up and cope with these behaviours.”
She says while resilience is important it is not the answer to workplace bullying and there needed to be a culture change from the top to create a workplace environment where responding to bullying is taken seriously.
“As when bullying is still tolerated and normalised, managers aren’t following it up because they don’t have to.”
The culture change needs to include training and support for direct line managers, like charge nurse managers, who are often the first port-of-call for nurses reporting bullying, says Blackwood.
Particularly as one of her key research findings is that bullied nurses’ reports of bullying are often snubbed or trivialised so they are put off reporting again.
Blackwood says poor leadership skills is one of the workplace factors that heightens the risk of bullying and is not helped by nursing’s tradition of often promoting managers based on clinical rather than leadership abilities.
This can leave managers not only struggling to respond appropriately to bullying reports but also with handling performance management issues which – if done badly – can be perceived as bullying by the nurses involved.
So this is why leadership training in areas like identifying bullying and conflict management skills are very important, believes Blackwood, so fewer managers’ default action is little or ‘no action’.
A lot of the behaviours that can constitute bullying can be subtle and appear almost petty or trivial – like being ignored or having your work criticised – but when they are targeted and happen over and over again they can become really harmful, says Blackwood.
On the other hand, a one-off incident, like a colleague losing their temper, is not bullying and neither is undergoing performance management. There also can be a fine balance between identifying bullying too early and creating a greater issue than actually exists, and identifying it too late when the bullying has escalated and low level interventions like mediation are less likely to be effective.
Focus groups that Blackwood held with managers, and others at the receiving end of bullying complaints, expressed how very difficult they find dealing with bullying cases – often taking the strain home with them at night. They spoke of sometimes being hamstrung from intervening by the bullied nurse not wanting the ‘bully’ to know about the complaint for fear of repercussions; and also the difficulties of dealing with a generation more accustomed to praise than criticism, which could make it very difficult to performance manage some staff.
Blackwood says different strategies were also needed for dealing with, for example, the ‘known bully’ who gets away with it as they are thought irreplaceable; than were needed for the ‘teacher-student’ bullying of a new graduate nurse too scared and inexperienced to realise they are being targeted.
Bullying reporting channels also needed to be clear, well known and reflect the complexities of bullying. So expecting nurses to report bullying via a DHB’s incident reporting system was “extremely problematic”. It could also be a “huge problem” if the only informal reporting channel is a nurse’s direct line manager, when it is the manager they are alleging is the bully.
Blackwood is keen to emphasise her research is “not about hauling DHBs across the coals”.
She says the dilemma is not a lack of DHB awareness of bullying as an issue but having the tools and knowledge to change the workplace culture and reduce the risk of bullying and bullying going unchecked.
At the same time funding constraints help not hinder the risk of workplace bullying – because as one nursing leader put it, a funding ‘sneeze’ at the top can impact like ‘pneumonia’ on front line staff. And Blackwood says stress is definitely one channel through which bullying develops and some of that stress also definitely comes through underfunding and the pressure that can place on frontline nurses.
“One of my key strategies (for addressing workplace bullying) is the need to work on organisational culture change but that can take a huge amount of time and resources – both of which DHBs have very little of.”
But Blackwood doesn’t believe this means change can’t happen –she has heard examples of simply the change of DHB leadership making a difference to a hospital’s readiness to intervene on bullying. She is also keen to contribute herself by investigating tools that could make a difference including seeking research funding to implement and evaluate a bullying intervention.
Because leaving their job should be the last resort, not the only option, open to a bully’s victim.
The director of nursing at Waikato District Health board said her fellow nursing director colleagues are aware of concerns about bullying and she personally investigates any that come to her attention.
“Many things are not at all bullying – just someone who has had a bad day and has interpreted somebody’s action in a different way,” says Hayward.
“But I think, with the increasing pressures placed on individual nurses and nurses as a whole, we have stopped being quite as kind to each other as we should be.”
She adds that in society as a whole she sees a real lack of courtesy.
“Standards of good behaviour just don’t seem to exist or don’t seem to be embedded in society to the degree that they once were.”
Hayward says nurse managers wanting to create a caring environment for their nursing staff need to “role model, role model, role model”.
“Role model, listen to staff, acknowledge their concerns, never minimise them or never marginalise an individual because of what they are saying – that’s my mantra.”
The Massey University professor and executive director of the believes nursing should be very concerned about it.
But whether bullying as it is defined today has always been a factor in nursing she finds hard to say. Back in the early 1970s, when she trained, nursing was so hierarchical and militaristic that she doubts many recognised they were being bullied although they almost certainly were. The difference was that it was not individualised bullying and “there was a sense we were all in it together”.
“We used to do ridiculous things like a first-year student had to stand up when a second-year student came into the room.
“And you had to turn sideways when the matron was walking down the corridor – the most extraordinary, antiquated, bizarre behaviours that we took as normal.”
That type of behaviour was in its dying days in the early 70s but student nurses still had to accept they were at the bottom of the pecking order and senior people would be “very, very hard on them” or they left. And leave they often did. “The attrition rate was huge.” It was also one of the reasons that training was shifted from the hospital model to polytechnics.
Carryer says individualised bullying between nursing colleagues today is “absolutely an oppressed group behaviour” with the sociological literature describing it as horizontal violence. “So where nurses feel hugely valued – and hold appropriate power and control over their own destiny – I suspect that bullying decreases markedly.”
Add to the mix hospital nurses working under the everyday challenge of rostered and rotating shifts and the pressure of constant change and it is no surprise that there is bullying in nursing, believes the professional nursing advisor for the New Zealand Nurses Organisation.
Brinkman says there is no magic answer to the systemic and human factors that lead to some people bullying and being bullied. But probably not helping was the constant push for change, calls to do more with less, stress caused by rostered and rotating shifts, and a lack of mental health skills and political awareness in many nurses.
“We might clinically be able to help someone with blood pressure but we don’t necessarily get it right when it comes to helping ourselves be more resilient and less bullied as a profession in an increasingly stressful environment.”
Brinkman says though there is no single answer to solving bullying, nurses should remember standard 1.1 of the Nursing Council Code of Conduct – which says treat people with kindness and consideration.
Also a “skilled, experienced and balanced charge nurse manager (CNM) who can lead, manage and inspire is worth their weight in gold” believes Brinkman. Though she echoes Karen Blackwood in saying too many CNMs are promoted because of their clinical expertise, and historically and nationally there was “very inadequate orientation” for CNMs who need leadership education and support to do their job well and create a caring environment for their staff.
But meanwhile nurses can be aware of their own strengths and weaknesses, work on having a balanced life and strive to be kind, considerate and supportive of each other.
Numerous negative behaviours towards a single target over a period of time that makes the target feel powerless and causes personal harm.
Definition used in Kate Blackwood research
Workplace bullying is repeated and unreasonable behaviour directed towards a worker or a group of workers that creates a risk to health and safety. Unreasonable behaviour includes victimising, humiliating, intimidating or threatening a person.
Definition used by WorkSafe New Zealand
Kate Blackwood (2015) Workplace Bullying in the New Zealand Nursing Profession: The case for a tailored approach to intervention, PhD thesis, Massey University