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Have you ever wanted to publish an article or had a great idea that you would like to see in print? The goal of CM Matters is to be a reflection of what you're doing and how you're dealing with challenges and triumphs. We hope you are enjoying CM Matters and will share some of the "how-tos, whys, and WOWs" of your case management experience. CM Matters is designed to give you an opportunity to show how case management matters and how, as a case manager, you have affected individuals, stakeholders, systems, cost-savings, and outcomes or just about anything else that is important to you and your colleagues.
CM Matters welcomes you and invites you to submit articles, stories, practice tips, reflections, and revelations. How has CM changed you and/or how have you affected the lives of others? All inquiries, questions, comments, and manuscripts should be submitted via e-mail to: mailto:email@example.com or by mail to Lynn S. Muller, P.O. Box 164, Bergenfield, NJ 07621. If you have an idea for an article but would like to discuss it, provide contact information in your e-mail and you will be contacted by your preferred method.
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One would have thought that by 2014, the issue of workplace bullying would be a thing of the past, but regrettably, it has become increasingly prevalent in health care and there are significant data to support bullying befalls and carries devastation. The zone of silence that surrounds and insulates this surreptitious behavior is real. In an environment in which bullying is not addressed, it often spreads. Ramifications of workplace bullying affect employees as well as patients and can lead to decreased reimbursement, unsafe conditions, and increases in errors, in addition to an overall negative reputation for an organization. Recently, studies have suggested that there is a direct correlation between professional nursing educational programs and decreased incivility in the workplace. Research studies support that when bullies in the workplace are held accountable, staff is more empowered and feels more confident to come forward and report these events. Through education, awareness, and prevention, nursing educational programs can be instrumental in eradicating this behavior both in the academic world and throughout the health care continuum. In the academic arena, undergraduate nursing students could benefit from evidence-based education demonstrating the ramifications of bullying and how to identify and address this all to prevalent behavior in their practice. Hospital-based nursing education programs, outlining policies and acceptable behaviors, are another forum that could help prevent workplace violence. Researchers agree that additional studies are needed to examine the effectiveness of nursing educational programs on eliminating covert bullying.
There are many theories on why some nurses, as well as leaders, chose to bully. While bullying in the health care setting has been recognized internationally, there is still a culture of silence in the Unites States, perpetuating underreporting, insufficient, and unproven interventions (Gaffney, DeMarco, Hofmeyer, Vessey, & Budwin, 2012). Work Place Bullying (WPB) is a global problem that has been recognized in many countries and within multiple occupations (Einarsen & Hoel, 2001). In January 2009, The Joint Commission required hospitals to have "code of conduct" polices, defining acceptable and inappropriate behaviors (Pisklakov, Tilak, Patel, & Xiong, 2013).
There are a variety of words associated with bullying that are used interchangeably, which include mobbing, aggressive behavior, incivility, harassment, horizontal violence, nurse hostility, and lateral violence. According to Meissner (1986), nursing hostility is a process of insidious cannibalism that will destroy the profession more than all feared outside sources. Additional disruptive behaviors include shunning, shaming, or criticizing team members in front of others; threatening team members with retribution, litigation, violence, or job loss; throwing instruments, and hurling charts or other objects (Pfifferling, 2008). Stealing ideas and work from others, such as taking credit for another's innovation, can also be a sign of bullying.
The core for all case managers, including nurses, should be creating a safe environment and delivering the highest quality of care and service consistent with the Standard of Practice (Case Management Society of America (CMSA), 2010). Case managers who practice in an environment of bullying and hostility are unable to function at their highest degree of quality and professionalism. No matter the case manager's discipline of origin, it has been proven that physical, psychological symptoms directly influence a nurse's ability to emotionally and physically render high-quality nursing care (Vessey, Demarco, Gaffney, & Budin, 2009), and there is reason to believe that all professionals are impacted similarly. Nurses who experienced bullying, directly or indirectly, were more likely to quit their jobs, but surprisingly nurses who watched others being bullied were just as likely to want to quit (Belsky, 2012). Research shows that as many as 60% of novice nurses leave within 6 months of being hired in their first nursing position as a direct result of the mistreatment they receive from other nurses (Rocker, 2008). Sadly, and all too often today, we learn about someone taking his or her life because of being bullied. For some, the shunning, exclusion, and persistence attacks are far more than they can handle. This, coupled with the belief that there is no safe haven and no way to affectively report these destructive behaviors, leaves case managers and their colleagues with a feeling, at the least of frustration, and at worse desperation, a position that can have grave results.
Bullying in the workplace is not just a moral problem; it is a managerial and an economic problem as well. Because the impact of bullying has many victims and is costly to the organization, there is a real need to address and correct this destructive behavior immediately. Bullying is linked to higher employee turnover rates (Belsky, 2012). Audacious management styles can foster a climate or disrespect, which can fuel aggressive and destructive behavior. Leaders and administrators who practice aggressive management and bullying tactics create an atmosphere of peril and jeopardize the safety of staff and patients. Managers who practice inimical methodologies need to be reeducated and stop reaping benefits from their antagonistic behaviors. Because weak leadership and failure to assume responsibility in cases of interpersonal conflict have both been identified as major risk factors, any action taken to increase leader competence in dealing with bullying is of the utmost importance (Salin, 2008). Climates exist among peers that can fuel this aggressive behavior; however, the sheer brashness of some leadership styles can also encourage these behaviors (Pfifferling, 2008).
Experts suggest that clear codes of conduct with zero tolerance for bullying are necessary, in addition to leaders taking ownership and encouraging case managers to report bullying (Cleary, Hunt, & Horsfal, 2010). Tolerance for violence in the hospital and health care setting by hospital administration must end. This assertion is in concert with recent Agency for Healthcare Research and Quality patient safety and American Association of Critical-Care Nurses healthy workplace initiatives (Howerton-Child & Mentes, 2010).
In Provision 1[S]1.5 of the American Nurses Association (2010) Code of Ethics for Nurses, the Code specifically addresses the need for respect anyone with whom the nurse interacts, as well as "Caring and companionate relationships with colleagues and others." Case management has inconsistencies in its guidance. Standard K, the Ethics Standard, of the CMSA Standards of Practice mandates "Maintenance of respectful relationships with coworkers, employers and other professionals." However, the entire focus of the principles contained in the Commission for Case Management Certification (2009) Code of Professional Conduct for Case Managers is directed toward maintaining and furthering the integrity, rights, and dignity of clients (patients) and the public but lacks anything addressing the importance of respect, support, and a healthy work environment for fellow case managers and colleagues.
Early intervention and getting prompt information about unacceptable behavior are important. Salins' (2008) study showed five aspects of prevention and monitoring of workplace bullying: surveys, written policies, training, information, and the statistical reporting of the number of cases found (Salin, 2008). Interventions for incivility and bullying behaviors are needed at both individual and administrative levels (Felblinger, 2008). In addition, the results of the study done by Salin showed that formal practices, including educational programs, human resource involvement, policies, and codes of conduct, decrease the prevalence of bullying (Salin, 2008). To date, efforts focused on the prevention and management of WPB have not been based on an empirical understanding of the WPB phenomenon (Chipps & McRury, 2012). Data collected supported that the validity of interventions to reduce WPB received little attention in the literature (Chipps & McRury, 2012).
A limitation in the literature exists because there are few studies that have evaluated and measured the effectiveness of the intervention. Although the research consists mostly of qualitative design, all experts suggest that quantitate research is needed to measure interventions. Some preventive measures include leadership awareness, educational training, formulating policies, monitoring the work environment, and improved communication (Salin, 2008). In a recent study, Howerton-Child and Mentes (2010) has proposed the education and training of all staff, to prevent workplace violence. Development of interventions to facilitate a positive work environment will require application of new and exciting paradigms, as well as thoughtful exploration and recreation of the conventional work environment (Felblinger, 2008).
While workplace bullying has been acknowledged as a threat to patient outcomes, as well as the erosion of personal health and professional well-being, strategies and interventions need to be further explored (Gaffney et Al., 2012). However, present studies provide some preliminary evidence that organizations are starting to make active efforts to prevent workplace bullying (Salin, 2008). The phenomenon of bullying is complex and intense in its nature with a propensity to shatter lives. Human resource departments along with professional education, at the undergraduate and graduate levels, along with continuing education can set the stage for awareness.
When hospitals are safer for staff, they will be safer for patients (Howerton-Child & Mentes, 2010). Elementary and high school systems, as well as law enforcement communities, have already made efforts to move forward in their attempts to address bullies and bully-like behavior. The February 2014 National Football League Report Concerning Workplace Conduct revealed that overt acts of physical and verbal bullying were prevalent even in an environment of otherwise perceived highly trained and very strong individuals. The report concluded that "even the largest, strongest and fleetest person may be driven to despair by bullying, taunting and constant insults. We encourage the creation of new workplace conduct rules and guidelines that will help ensure that players respect each other as professionals and people" (Paul, Karp, Birenboim, & Brown, 2014, p. 140). Clearly, the health care environment is far from the only workplace where harassment, verbal slurs, and worse can be found.
Case management, with its prevalence of nurses and other critically necessary professionals, has the highly educated practitioner in such numbers and the resources to not only adhere to the Standards of Practice but also demonstrate leadership in the most meaningful way possible; take the lead and lead by example, rather than perpetuating this decades old destructive practice.
American Nurses Association. (2010, November 15). Code of ethics with interpretive statements. Retrieved February 27, 2014, from Nursing World website: http://www.nursingworld.org/codeofethics[Context Link]
Belsky G. (2012, July 12). Workplace bullying: The problem, and its costs, is worse than we thought. Careers & Workplace, Times, p. 1. [Context Link]
Case Management Society of America. (2010). Standards of practice for case management. Little Rock, AR: Case Management Society of America. [Context Link]
Chipps M. E., McRury M. (2012). The development of an educational intervention to address workplace bullying: A pilot study. Journal for Nurses in Staff Development, 28(3), 94-98. [Context Link]
Clark M. C., Olender L., Cardoni C., Kenski D. (2011). Fostering civility in nursing education and practice. Journal of Nursing Administration, 41, 324-330.
Cleary M., Hunt E. G., Horsfal J. (2010). Identifying and addressing bullying in nursing. Issues in Mental Health Nursing, 31(33), 1-335. doi: 10.3109/01612840903308531 [Context Link]
Commission for Case Management Certification. (2009). Code of professional conduct. Florham Park, NJ: The Commission for Case Management Certification. [Context Link]
Einarsen S., Hoel H. (2001, May). The Negative Acts Questioner: Development validation and revision of a measure of bullying at work. Oral presentation at the 10th European Congress on Work and Organizational Psychology, Prague, Czech. [Context Link]
Felblinger M. D. (2008). Incivility and bullying in the workplace and nurses' shame responses. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(2), 234-242. doi: 10.1111/j.1552-6909.2008.00227.x. [Context Link]
Gaffney A. D., DeMarco F. R., Hofmeyer A., Vessey A. J., Budin C. W. (2012). Making things right: Nurses experience with workplace bullying-A grounded theory. Nursing Research and Practice, 1-10. http://dx.doi.org/10.1155/2012/243210[Context Link]
Howerton-Child R. J., Mentes C. J. (2010). Violence against women: The phenomena of workplace violence against nurses. Mental Health Nursing, 31, 89-95. doi: 10.3109/01612840903267638 [Context Link]
Meissner J. (1986). Nurses are we eating our young? Nursing, 16(3), 51-53. [Context Link]
Paul W. R, Karp B. S., Birenboim B., Brown D. W. (2014, February 14). Report to the National Football League Concerning Issues of Workplace Conduct at the Miami Dolphins. Retrieved February 28, 2014, from The New York Times website: http://63bba9dfdf9675bf3f10-68be460ce43dd2a60dd64ca5eca4ae1d.r37.cf1.rackcdn.com[Context Link]
Pfifferling J. H. (2008). Physicians' disruptive behavior: Consequences for medical quality and safety. American Journal of Medical Quality, 23, 165-167. doi:10.1177/1062860608315338 [Context Link]
Pisklakov S., Tilak V., Patel A., Xiong M. (2013). Bullying and aggressive behavior among health care providers: Literature review. Advances in Anthropology, 3(4), 179-182. [Context Link]
Rocker C. (2008). Addressing nurse-to-nurse bullying to promote nurse retention. OJIN: The Online Journal of Issues in Nursing, 13(2), n.d. doi: 10.3912/OJIN.Vol13No03PPT05 [Context Link]
Salin D. (2008). The prevention of workplace bullying as a question of human resource management: Measures adopted and underlying organizational factors. Scandinavian Journal of Management, 1-19. doi: 10.1016/j.scaman.2008.04.004. [Context Link]
Vessey A. J., Demarco F. R, Gaffney A. D., Budin C. W. (2009). Bullying of staff registered nurses in the workplace: A preliminary study for developing personal and organizational strategies for the transformation of hostile workplace environment. Journal of Professional Nursing, 25(5), 299-306. [Context Link]
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