Introduction

Negative workplace behavior1 has been studied for decades under many names including, but not limited to: incivility,2 bullying,3 horizontal violence,4 lateral violence5 and vertical violence.6 The profession of nursing seems particularly vulnerable to negative workplace behavior as evidenced by the growing body of literature on violence in the workplace among nurses.7-9 Over decades, multiple studies have explored the prevalence of this phenomenon, descriptions of violence, outcomes of violence and theories about violence among groups, including nurses.10-13

Meissner14 first coined the term "nurses eat their young" 30 years ago in a landmark article leading to the recognition of vertical violence, or the violence of senior nurses to novice nurses entering the profession. Vertical violence is violence occurring between people with unequal power, i.e. staff nurse and student.6,15 The assumption of vertical violence is that it is downward; nurse managers and nurse educators are in positions of authority and are the ones with the "tools" to cause harm to their subordinates. Meissner followed with a second article 13 years later, questioning if any progress had been made and found little had changed.16 The later article suggested that educators, administrators, managers and patient caregivers should "re-examine their interactions with novice nurses for the sake of maintaining high standards for the profession".16^(p.43) Recent estimates have reported that 48% of graduating nurses are fearful of workplace bullying and more than 60% of all new nursing graduates leave their first job due to negative workplace behavior directed at them.15 Several studies have identified nurses in management positions and senior staff nurses as the perpetrators of uncivil behavior,17-19 and at the same time being the most responsible for engaging in management strategies to eradicate incidences of workplace violence.6

Workplace violence between people of equal power (peer to peer) has been labeled lateral or horizontal violence. Lateral violence has been studied for over four decades and further complicates workplace relationships with bullying or incivility between employees.5,9,12,20 Lateral violence is prevalent in the nursing workforce and can have a profound impact on patient safety and performance of the nursing team, in addition to the personal impact on each individual nurse.21,22 Again, new graduate nurses have been identified as vulnerable to the rudeness, sabotage, scapegoating, gossiping and passive-aggressive communication often associated with lateral violence.23,24 Negative workplace behavior contributes to job dissatisfaction and burnout25 and influences personal employment decisions to change workplaces and, in more extreme cases, leave the profession of nursing altogether.26,27

The increasing incidence of negative workplace behavior has received significant attention over decades, but only modest attention has been given to vertical violence directed upwards, at a person in authority.28 Upwards violence may begin with incivility and include verbal threats, rudeness, social ostracizing, bullying, mobbing and/or passive aggressive behavior. Upwards violence can quickly escalate to more threatening aggressive retaliatory actions against the person in authority.29 Multidisciplinary researchers around the globe are increasingly interested in situations where managers and leaders are the targets of individuals or groups. The latter is referred to as mobbing in the nursing literature and while there are few publications in the area of mobbing in nursing workplaces, it has been cited as a significant problem in nursing academia.30,31 The upwards direction of vertical violence and bullying first appeared in the literature towards the end of the last decade. It has been suggested that upwards bullying may be more difficult to detect32 due to presenting in more subtle ways like gossiping and criticism. The literature further identifies that upwards violence may be an impetus for a hostile or toxic work environment and contribute to a loss of effective management.33

Upwards violence demoralizes nurse leaders and threatens future generations of nurses, deterring them from seeking roles with authority and therefore, this is a topic of great importance for nurses in leadership positions and for the nursing profession. A synthesis of findings of nurses' experience of upwards violence will help us understand this type of violence, including its impact on nurse leaders. Knowledge gained from this systematic review will inform interventions and strategies that nurse managers, nurse administrators and nurse educators can develop and use to reduce the incidence of upwards violence and minimize the negative economic and psychological consequences associated with this workplace violence. For example, knowledge about upwards violence may help identify the context or environmental factors, which may be modified to reduce upwards violence. Knowledge about the actual experience of upwards violence may lead to the identification of strategies to support the target of the violence, and will help the target and others in the organization to recognize when upwards violence is occurring.

Upwards violence is a term that has only come into use in the past decade, and since that time there has been growth in research on this topic.28-33 A preliminary search was conducted in CINAHL, MEDLINE, Embase, Scopus, Web of Science, PsycINFO, ABI INFORM, LexisNexis Academic and Sociological Abstracts to locate any systematic review on upwards violence in nursing and none was found. Therefore, it is timely that a systematic review be conducted to synthesize findings. The proposed qualitative systematic review will synthesize what is known about nurse leaders' experience of upwards violence. The main objective of this review is to understand nurses' experience of upwards bullying. An secondary objective is to suggest implications for nursing practice and research that are based on the synthesized findings.

Inclusion criteria

Participants

Participants will be nurse leaders who have said they experienced upwards violence in nursing workplaces from persons they supervise. Nurse leaders are registered nurses or nurse practitioners who are employed in a position where they supervise other nursing personnel (e.g. registered nurses, licensed practical nurses, nurse practitioners, student nurses, etc.). The positions held by the nurse leaders will include all roles (e.g. nurse manager, clinical nurse specialist, nurse practitioner) where the position responsibility includes supervising the work of other nursing personnel. Participants will be English speaking only.

Phenomenon of interest

The phenomenon of interest will be the experience of upwards violence in nursing workplaces, which is violence directed towards nurse leaders who, based on their organizational role, have authority over the person who directs the violence towards them. The persons directing the violence towards the nurse leader may be any category of nursing personnel (e.g. registered nurses, licensed practical nurses, nurse practitioners, student nurses, etc.).

Context

The context will be all workplace settings (i.e. acute care and non acute care) in any country where the nurse leaders describe their experience in English and where nurse leaders supervise other nursing personnel.

Types of studies

This review will consider all studies that use all types of qualitative methodology (e.g. phenomenology, grounded theory, ethnography, action research, feminist research, narrative, case study, mixed-methods) and provide direct quotations that can be extracted from the nurse leader participants about the phenomenon of interest. The studies will be published from the year 2000 onward, and only in English. Given that upwards bullying was a term introduced only in the past decade by Branch,35 we anticipate that most studies that specifically refer to upwards bullying or violence will be qualitative. Our focus is on papers published since 2000 because we are interested in describing upwards violence in organizational contexts today, and not in organizational contexts that operated in earlier periods where widely different laws, human rights and human resource practices were in place.

Methods

The methodology for this systematic review will be that described in the Joanna Briggs Institute Reviewer's Manual.34

Search strategy

The search strategy will aim to find both published and unpublished papers. A three-step search strategy will be used. An initial limited search of CINAHL and MEDLINE will be undertaken using the phrases "upwards bullying" or "upward bullying," followed by analysis of the text words contained in the titles and abstracts, and of the index terms used to describe the articles. This process will inform the development of a search strategy which will be used for each information source. The second step is a full search strategy for databases noted below and using specific search strings shown in Appendix I. Following the initial phrase search ("upwards bullying" or "upward bullying"), we will develop a full search strategy, expanding the search concepts of upwards bullying to other terms (such as "incivility", "violence", "aggression", "vertical bullying", "mobbing", "harassment", "relational aggression" and "interpersonal hostility"). Third, the reference lists of all papers selected will be screened for additional papers and other unpublished relevant items.

Information sources

The databases to be searched include: CINAHL, MEDLINE, Embase, Scopus, Web of Science, PsycINFO, ABI/INFORM, LexisNexis Academic, Sociological Abstracts.

The search for unpublished literature will include: Factiva, OpenGrey, ProQuest Dissertations and Theses Global, ProQuest Dissertations Open, Health Business Elite, Google Scholar.

Study selection

All identified citations will be collated and uploaded into RefWorks (ProQuest LLC, Ann Arbor, USA) and duplicates removed. Two reviewers will independently assess titles and abstracts to identify studies that may meet the inclusion criteria for the review. Articles that may meet the inclusion criteria will be retrieved in full and their details imported into the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). These full texts will be judged in detail against the inclusion criteria. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram.36 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Assessment of methodological quality

Two reviewers will independently critically appraise the studies selected for methodological quality, using the criteria in the JBI Critical Appraisal Checklist for Qualitative Research.34 The two reviewers will discuss studies that either of them has rated two or more criteria as "no" or "unclear" and come to an agreement if the study will be included in the systematic review. A third reviewer will critically appraise a study in the event the first two reviewers disagree. Our predetermined decision to exclude studies with four or more criteria rated "no" or "unclear" will ensure that only studies with a high level of rigor will be included in the systematic review.

The number of studies that are assessed as both meeting and not meeting the criteria for methodological quality will be noted in the PRISMA flow diagram. The results of the critical appraisal will also be reported in a table and within the narrative of the systematic review.

Data extraction

The extraction of data will be completed using the standardized data extraction tool entitled JBI Qualitative Data Extraction Tool.34 This extraction will be conducted by two independent reviewers. Data extracted will include details about the nurse leaders who have experienced vertical violence, the context and country, the phenomenon of interest (upwards violence) and study methods. Each study's findings and their illustrations will be extracted and assigned a level of credibility. In the case of missing information or the need for clarification, we will attempt to contact the authors of the primary studies.

Data synthesis

Qualitative research findings will be pooled, where possible, using JBI SUMARI with the meta-aggregation approach.37 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.

Assessing certainty in the findings

The ConQual approach38 to assess confidence in the synthesis of the qualitative research findings will be used. This will be presented in a Summary of Findings, which includes the title, population, phenomena of interest and context of the systematic review, and how the ConQual Score is developed. For each synthesized finding the type of research leading to it, the scores for dependability and for credibility, along with the overall ConQual score will be shown.

Appendix I: Search strategy

Specific search strategies we will use in CINAHL and MEDLINE searched within Ebsco are shown below. These search strings will be modified as appropriate for the other databases noted in this protocol.

CINAHL

MH "Aggression" OR MH "Bullying" OR MH "Verbal Abuse" OR MH "Incivility" OR TI aggression OR AB aggression OR TI bullying OR AB bullying OR TI bullied OR AB bullied OR TI incivility OR AB incivility OR TI abuse OR AB abuse OR TI violence OR AB violence OR TI mobbing OR AB mobbing OR TI hostil^* OR AB hostil^*

AND

MH "Nurse Administrators" OR MH "Nurse Managers" OR MH "Charge Nurses" OR MH "Head Nurses" OR MH "Nursing Management" OR TI "nurs^* manag^*" OR AB "nurs^* manag^*" OR TI "nurs^* administrat^*" OR AB "nurs^* administrat^*" OR TI "nurs^* leader^*" OR AB "nurs^* leader^*" OR TI "head nurses" OR AB "head nurses" OR TI "senior nurse^*" OR AB "senior nurs^*" OR MH "Faculty, Nursing"

AND

TX (attitude^* OR perception^* OR perceive^* OR experience^* OR observ^* OR view^* OR witness^* or react^* OR act^* OR deconstruct^*)

MEDLINE

MH "Aggression" OR MH "Bullying" OR MH "Verbal Abuse" OR MH "Incivility" OR TI aggression OR AB aggression OR TI bullying OR AB bullying OR TI bullied OR AB bullied OR TI incivility OR AB incivility OR TI abuse OR AB abuse OR TI violence OR AB violence OR TI mobbing OR AB mobbing OR TI hostil^* OR AB hostil^*

AND

MH "Nurse Administrators" OR MH "Nurse Managers" OR MH "Charge Nurses" OR MH "Head Nurses" OR MH "Nursing Management" OR TI "nurs^* manag^*" OR AB "nurs^* manag^*" OR TI "nurs^* administrat^*" OR AB "nurs^* administrat^*" OR TI "nurs^* leader^*" OR AB "nurs^* leader^*" OR TI "head nurses" OR AB "head nurses" OR TI "senior nurse^*" OR AB "senior nurs^*" OR MH "Faculty, Nursing"

AND

TX (attitude^* OR perception^* OR perceive^* OR experience^* OR observ^* OR view^* OR witness^* or react^* OR act^* OR deconstruct^*)

References