The prevalence of nursesʼ perceived exposure to workplace bullying and its effect on nurse, patient, organization and nursing-related outcomes in clinical settings: a quantitative systematic review protocol

Abstract

Review question/objective To systematically review the literature to determine the best available evidence on nurses' perceived exposure to workplace bullying, as measured by the Negative Acts Questionnaire-Revised (NAQ-R), and its effect on nurse, patient, nursing and organization-related outcomes, including psychological and behavioral responses, job satisfaction, work productivity, medical errors, and intent to leave employment or the nursing profession. Specifically, we aim to find answers to the following questions: What is the prevalence of nurses' perceived exposure to workplace bullying in clinical settings? What is the effect of nurses' perceived exposure to workplace bullying, as measured by the NAQ-R, on nurse, patient, nursing and organization-related outcomes, including: Psychological and behavioral responses (nurse-related outcome) Job satisfaction (nurse-related outcome) Work productivity (nurse-related outcome) Medical errors (patient-related outcome) Intent to leave (job or nursing)(organization and nursing-related outcomes). Background For more than forty years, researchers from around the globe have studied several concepts that are used to name acts of disrespect or mistreatment that can occur between and among nurses working in clinical settings. These concepts include, but are not limited to, workplace incivility,1 lateral or horizontal violence,2 disruptive behavior,3 and workplace bullying (also called mobbing in some countries).4–6 Workplace incivility breaches expected norms of conduct for reciprocal respect among workers.7 The concept of horizontal violence originated in oppression theory.8–9 Horizontal violence is fighting within an oppressed group that may arise as a way to release mounting frustration from the inability to attack the oppressor. Roberts used this theory to explain nursing as an oppressed group who is at risk for horizontal violence.10 Disruptive behavior is misconduct that occurs between health professionals that ranges from non-physical to physical to sexual harassment that injures or daunts the recipient and potentially threatens the safety and quality of patient care.11 Although the definition of workplace bullying varies from country to country and culture to culture, there are commonalities: Bullying is persistent and systematic victimization of a target with repeated use of negative acts over a long period of time to the extent that the target(s) struggles to defend him/her/themselves.12 In some countries, the term mobbing is used instead of workplace bullying.5–6 In 1990, Heinz Leymann, a psychologist, was first to use mobbing to name psychological harassment among adults at work that includes repetitive negative actions over at least a period of six months to the point where the target becomes defenseless. Further, the target of the mistreatment suffers devastating emotional, physical and social consequences.14 Leymann reserved the term “bullying” for physical aggression that occurs between children in the school yard. At about the same time that Leymann was conducting his research on mobbing in Sweden, Andrea Adams, a British journalist and activist, and Neil Crawford, a psychotherapist, used the term bullying to name behavior that terrorizes adults in their place of work.15 A few scholars posit that these concepts are not the same. Instead, they place some of them along a continuum of lessor to greater intensity of negative workplace conduct.7,16–18 Workplace incivility is on the lessor end of the continuum. Workplace bullying, on the other hand, is on the higher end of the continuum as it is of greater intensity than workplace incivility. Investigators have not yet addressed where disruptive behavior and horizontal violence sit on the continuum of negative workplace conduct. To date, two systematic reviews, one about lateral/horizontal violence in nursing and one about successful interventions for managing disruptive behavior within the nursing work environment have been published in the JBI Database of Systematic Reviews and Implementation Reports.19–20 In the Cochrane Library, one protocol was found that focused on interventions for prevention of bullying in the workplace for a broad population of employees in paid work within public, private or voluntary organizations.21 This review will to add to extant work and focus on the concept of workplace bullying among nurses in clinical settings. Einarsen, Hoel, Zapf and Cooper's most recent definition of workplace bullying will be used in this review because it is cited at various stages of conceptual development in a number of studies in nursing: “Bullying at work means harassing, offending, socially excluding someone or negatively affecting someone's work tasks. In order for the label bullying (or mobbing) to be applied to a particular activity, interaction or process it has to occur repeatedly and regularly (e.g. weekly) and over a period of time (e.g. about six months). Bullying is an escalating process in the course of which the person confronted ends up in an inferior position and becomes the target of systematic negative social acts. A conflict cannot be called bullying if the incident is an isolated event or if two parties of approximately equal strength are in conflict.”12(p22) Researchers have used a variety of measures to assess nurses' exposure to workplace bullying.22–24 Einarsen, Hoel and Notelaers developed the Negative Acts Questionnaire-Revised (NAQ-R), a 22-item measure of exposure to workplace bullying, which was administered in several nursing studies internationally.18,24–25 Three subscales exist within these 22 items: (1) work-related bullying (seven items), (2) person-related bullying (12 items), and (3) physically-intimidating bullying (three items).17 Examples of items include: (1) “someone withholding information which affects your performance” (work-related bullying), (2) “being ignored or excluded or isolated from others” (person-related bullying), and (3) “being shouted at or being the target of spontaneous anger” (physically intimidating bullying).18(p32) In studies of nursing, researchers have assessed workplace bullying using the full 22-item measure,24–25 a 14-item modified version of it,26 or the three subscales separately.27 The NAQ-R measure was utilized most often to assess nurses' perception of workplace bullying in research, so studies in which this questionnaire was used will be the focus of this review because consistent use of the instrument makes comparison across studies feasible. Several scientists in different countries have conducted studies in nursing that aim to describe the frequency of exposure to workplace bullying and its association with nurse, patient, nursing and organization related outcomes. The reported frequency of exposure to workplace bullying in studies where researchers used any version of the NAQ-R ranged from 13 to 48%.28–29 In studies where researchers used the 22-item NAQ-R, nurses who experienced bullying in the workplace reported associated poor physical and mental health, job dissatisfaction, decreased work productivity, or they pondered leaving their job or nursing altogether.24–25,30–32 Furthermore, nurses perceived lower quality of care, lower patient safety, and higher risk of adverse events.33 In a study that assessed workplace bullying using the three NAQ-R subscales, person-related bullying was associated with medical errors, but work-related and physically intimidating bullying were not.27 To date, one of these outcomes has been linked to patient care. Nurses' job satisfaction was linked to quality of care and pressure ulcers and patient falls, indicators of patient safety.34–36 Workplace bullying is important to study because of its direct correlation to patient care and its indirect association with patient care via one of the outcome variables. However, no systematic review has yet been conducted on studies that use the NAQ-R to assess nurses' perceived exposure to workplace bullying in clinical settings. Prior to the commencement of this systematic review, the Cochrane Library and the JBI Database of Systematic Reviews and Implementation Reports were searched. No previous systematic reviews on the topic of nurses' perceived exposure to workplace bullying in clinical settings were identified. Hence, the objective of this systematic review is to describe nurses' perceived exposure to workplace bullying in clinical settings and its impact on nurse, patient, nursing and organization related outcomes. Inclusion criteria Types of participants This review will consider studies that include licensed nurses working in clinical settings in any country. For the purposes of this review and given possible differences in terminology internationally, “licensed nurse” pertains to, but is not limited to, Registered Nurse (RN), Licensed Practical Nurse (LPN), and Licensed Vocational Nurse (LVN). Likewise, “clinical setting” refers to any setting where nursing care is delivered to people, including, but not limited to, hospitals, long term care facilities, skilled nursing facilities, home care, ambulatory care clinics and outpatient clinics. Therefore, all titles for “licensed nurse” and “clinical settings” will be considered. Furthermore, “any country” refers to countries that are developed and those that are developing. Types of exposure This review will include studies that explore nurses' perceptions of exposure to workplace bullying in clinical settings, as measured by the Negative Acts Questionnaire-Revised, and its effects on particular outcomes. Types of outcomes This review will evaluate nurses' perceived exposure to workplace bullying, as measured by the NAQ-R, and its effect on nurse, patient, organization and nursing-related outcomes: (1) psychological and behavioral responses (nurse-related outcome), (2) job satisfaction (nurse-related outcome), (3) work productivity (nurse-related outcome), (4) medical errors (patient-related outcome), and (5) intent to leave the job (organization-related outcome) or nursing (nursing related outcome). Outcome measures will include but are not limited to: (1) the emotional exhaustion subscale of the Maslach Burnout Inventory General Survey and a modified version of a job performance survey (psychological and behavioral responses), (2) a subscale of the Job Diagnostic Survey (job satisfaction), (3) the Healthcare Productivity Survey (work productivity), (4) a scale derived from the American Nurses Association Nursing Quality Indicators and a modified version of a job performance survey (medical errors), and (5) the index of employee intention to leave, a subscale of the Michigan Organizational Assessment Questionnaire, and a researcher developed survey (intent to leave job or nursing).24–25,27,30–33 Types of studies This review will consider for inclusion both analytical and descriptive epidemiological study designs, including prospective and retrospective cohort studies, case control studies, case series, individual case reports, and analytic and descriptive cross sectional studies. Each study will be classified according to the JBI Levels of Evidence and preference will be given to those higher in the hierarchy of evidence such as randomized controlled trials (RCT). Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PUBMED and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the indexed terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, citation searching will be completed using Scopus and Google Scholar, and the reference list of all identified reports and articles will be searched for additional studies. Studies in languages other than English will be considered for inclusion only if they are translated into English. Studies published from 1990 to the present will be considered for inclusion in the review. The starting point for this search was chosen based on when literature that first described the phenomenon was published, i.e. Leymann's research on mobbing in Sweden.13 Databases to be searched include: BioMed Central, CINAHL, Embase, Psych Articles, PsycINFO, PUBMED, Science Direct, Scopus, SocINDEX, Web of Science, reference lists of identified studies and review papers. The search for unpublished studies will include: Google Scholar, MEDNAR, New York Academy of Medicine Grey Literature Report, and ProQuest Dissertations and Theses. Initial keywords to be used will be: nurses, nursing, workplace bullying, mobbing, incivility, disruptive behavior, horizontal violence, lateral violence, hospitals, skilled nursing facilities, home care, outpatient clinics. Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or a third reviewer. Data extraction Data extracted from papers included in the review by using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Authors of primary studies will be contacted for missing information or for clarification during the review. Data synthesis Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Prevalence will be summarized across all studies in a way that takes into account differences of sample size. Studies that look at the same outcome will be used in meta-analyses to investigate the association of bullying with each outcome. Conflicts of interest There is no conflict of interest between or among the reviewers. Acknowledgements The first and third reviewer would like to thank the University of San Francisco's Faculty Development Funds for the financial support needed to attend the Joanna Briggs Comprehensive Systematic Review training at the University of California; San Francisco (UCSF) Centre for Evidence based Patient and Family Care: an Affiliate Center of the Joanna Briggs Institute.