This extensive research tries to find the real face of bullying among nurse
managers in the NHS. Malcolm A Lewis looks at the truth behind the perceptions
This article, which explores the reactions of nurse managers to bullying
within the NHS, is part of a larger doctoral study into nurse bullying. The
research comes from the in-depth, relatively unstructured interviews of 10
nurse managers. Detailed analysis reveals their concerns and identifies key
themes, which influence their views on bullying.
The study takes an ethnographic approach to bullying in examining the
detailed worlds of both the managers and nurses; and is grounded in the
theoretical principles of symbolic interactionism. This approach is used
because no detailed micro-studies exist as to this phenomena in nursing, and as
an antidote to the predominance of quantitative and survey studies based on
psychological theory.
The data is extensive, but there is a summary of the main findings at the
end of the article.
Background
Managers are of particular interest, because research on bullying identifies
them a principle perpetrator of it in the workplace.1
Data reveals nurse managers inhabit ‘parallel worlds’ of nursing and
management, where role distinctions are blurred, and constant strains develop
between their ‘professional’ world and managerial paradigms. It creates a
‘Janus effect’, likened to the Roman two-faced God of doorways. Like Janus,
these managers are constantly looking towards their futures, but must also look
back to the clinical arena from where they came from. They therefore inhabit
dual worlds.
Hawley et al refers to the nurse manager’s world as being highly
interactive, with a need for information to be traded at many levels.2 The data
supports this, but also reveals concerns regarding nursing management abilities
to deal with bullying. It remains a complex phenomena, not least in respect of
its definition and temporal dimensions. Simply put, Clifton and Sirdar define
it as an abuse of power, while in nursing most bullying activity is
concentrated within clinical care environments; predominantly with superiors
bullying subordinates.3
However, a good deal of group and peer bullying takes place, particularly
from cliques. It is not possible in such a short account to analyse the
bullying phenomena in depth, but in examining the managers reactions to it, we
are able to reveal both specific and general concerns over bullying, and
specifics relevant to the nursing situation.
All the managers indicated an awareness of bullying activity in nursing, and
at least one manager in the study admitted to bullying behaviour ‘on occasion’.
The interview data revealed four major areas of concern. In order of priority,
they were:
1) The impact of negative managerial actions
2) Communications
3) Managers as targets of bullying behaviour
4) Lack of managerial skills and knowledge
The impact of negative managerial actions
Overall, the managers demonstrated a general negativity towards bullying. In
particular, they felt bullying or potential bullying incidents were approached
in the wrong way by people in the NHS. They often regarded issues such as
uncertainty and work pressures and the responses to them as being possibly
misinterpreted as bullying.
Notions of being ‘bullied’ were almost seen as a normal part of the nursing
culture, but not labelled as such. Managerial styles were described as almost
always being autocratic,2 and there was a fine line between being a firm
manager and being accused of bullying.
There was a widespread problem with definition, which reflects the general
trend encountered in target perceptions and findings in other studies.4 The
managers revealed an overall reluctance to deal with the phenomena, partly due
to this difficulty of definition and it’s nebulous and mainly covert nature.
There was also a feeling of a general lack of support from seniors, and a fear
of speaking out in case it led to censure. It was alluded to on a number of
occasions that complaints ‘don’t get anywhere’ and issues such as whistle
blowing in particular were given as examples of this.
This climate of fear, and the fact that the majority of bullying remains in
the clinical area contributes towards a condition of isolation for the manager.
Bullying is rarely dealt with outside their sphere of work, and they
overwhelmingly admit to understanding little about what takes place outside
their own clinical arenas.5
Robinson also refers to such isolationist activity, and that many nurse
managers leave issues open-ended, often delaying actions and developing a more
reactive style of decision-making.5 In respect of those, the effects are
traumatic. Not only is their problem not acknowledged or dealt with adequately,
but it is rarely given wider organisational attention. A major effect of
bullying behaviour is to isolate the ‘target’ in an attempt to make them feel
inadequate. The actions or inactions of these managers does little to help the
nurse in such a situation.
Communications
The predominant focus on communication by the managers was clinical
communication, where they were at ease. They saw their role principally as
mediators in handling bullying problems, which required adequate dialogue with
both the bully and the victim to reach a resolution. Such responses were
usually low key, unreported and localised.
This was another attempt to keep the event within well-defined parameters,
to be seen to be acting properly and avoiding wider (non-nursing) authority.
There seems to be a constant trade-off between being seen to act properly, and
maintaining a professional image – thus creating the need to keep the bullying
‘behind closed doors’. In one respect, doing so is to the probable benefit of
the parties involved, but it also creates other problems.
The meditative function expressed by many nursing managers is seen as
arising from the general social nature and team working central to nursing,6
but this may work against them as they may not learn to handle conflict
constructively, and may actually contribute towards the isolationist nature of
such managers.
Managers were at pains to point out that abusive and public confrontation in
clinical areas should not be tolerated, and was unprofessional. They
universally condemned managers who acted against staff in such circumstances.
Another reason behind this secrecy is that most managers admitted they had
poor knowledge of bullying and how to handle it. In most cases, they had
incomplete knowledge of the bullying events, and were not party to the whole
story.
Bullied nurses are also frequently reluctant to report such incidents, again
due to fear of censure or isolation. It is all too clear on examining workplace
bullying, and in nursing in particular, that peer support is frequently not
forthcoming.
While nurse managers on the whole make all the right noises in respect of
bullying support, where managers become the perpetrators, such communication
from nurse to manager becomes virtually impossible. Nurse managers are
predominantly responders to such events rather than initiators of action. Their
lack of knowledge can also be seen as a justification for their inaction, or
for an inability to act sufficiently to support a nurse or an investigation.
Managers were well aware of current issues in respect of NHS human resource
initiatives, especially the provision of staff counselling services – although
on the whole this was treated with some suspicion. All managers were aware of
the use of formal procedures to deal with bullying, but going to a higher
authority was often seen as making things ‘worse’.
In particular, the use of formal grievance procedures were often found
wanting. The processing of such a procedure is usually done through the line
manager, when they are frequently the perpetrator.
The manager as a target of bullying
The majority of managers in the study had witnessed bullying and had also
been subjected to it, with at least three being subjected to bullying at the
time of the interviews. The common perpetrators of this were more senior
managers, but they also reported significant bullying from subordinate groups.
This was a particular concern for new managers when bullying took place around
either a promotion, or threats to the nursing status quo.
Interactionist work on reference groupings indicates that individuals will
predominantly link to the reference groups from which they have most to gain.7
While this is a valid point, in the case of bullying, the phenomena distorts this
effect. While the majority of bullying is directed from senior managers to
juniors, the manager also needs to keep face and be seen to act in the
‘managerial way’. Questions have been asked as to whom such an individual is
performing;8 to what determines this reference relationship, and to what extent
managers define the situation.9
Dittes, however, is clear in his analysis of group attractiveness in stating
that a person tends to comply with the norms of the group they find most
attractive.9 The manager may feel bullied by subordinates if there is a need to
impose change, or there is a feeling that the manager has now abandoned the
‘clinical world’ of nursing. In this dilemma, the manager literally has to look
both ways; the ‘Janus effect’ being only too evident. The way managers cope
with such difficulties is usually better than their more junior colleagues.
The interference of the bullying acts on the professional functioning of the
nurse emerges in two distinct ways.10 First, the notion of professional
cohesion is questioned because bullying interferes with professional working –
being overwhelmingly demeaning to the nurse, in acts of abuse, isolation,
belittling among others. There is also a change in nursing demeanour, in so far
as the nurse now acts in specific ways to deal with the bullying event.
The data shows that while on a personal and professional level (such as in
relationships with colleagues, in particular) this can be devastating, the
effect of such bullying on the nurse’s professional care of patients is
minimal. This is because these nurses are at great pains to ensure that such
actions do not interfere with direct patient care.
In the case of nursing managers, there is a very similar scenario – the
bullying demeans the manager’s role, and interferes with professional work.
However, the study has revealed that in the move away from the clinical field,
as managers identify with the senior managerial reference group, this leads to
a weakening of professional cohesion at a clinical level. There would seem to
be less concern with the professional nursing impact of their actions, or
importantly upon the impact on patient care as the managerial career
progresses. In short, the actions of bullying by senior managers may have a
more direct and detrimental effect upon patient care than bullying by junior
managers of clinical nurses.
Unfortunately, the general lack of support was not a surprising feature.
Managers are very much left on their own to cope, and there is little support
at higher levels. They have already reported an overall lack of support in
their dealings with the bullying of nurses at lower levels, so we should not be
altogether surprised at the reluctance to act in many situations. More than one
manager had expressed sympathy with their superiors, because they indicated
bullying was taking place at the very highest levels, and pointed out that ‘the
rot is coming from the top’.
Managerial conceptions about the bully or bullies reflects much of the
clinical nurses’ views and experiences. Even where group bullying in ‘cliques’
is taking place, there is often an identifiable ring leader; a nurse whom in
the past has been identified as a ‘troublemaker’, or labelled as a bully.
Analysis of workplace bullies indicates that a large percentage of bullies
are ‘serial bullies’, who have been previously active and are well known to
engage in this type of behaviour.11 Managers may be in a difficult position in
dealing with such people or groups, and not simply due to the difficulty of
obtaining evidence and instigating action.
This study shows that bullies are highly devious people, who in the vast
majority of instances are only too well aware of their actions.12
Scott and Lyman have argued in their discussion on vocabulary of motive that
such is the hierarchy and authority attributed to such an individual, it
becomes a relatively simple matter for them to orchestrate any group bullying
behaviour, and hide within the group protection if there are any ensuing
machinations.12
While we may consider in all bullying events this unequal distribution of
power, such can be the power of such group and individuals that the ability of
the manager to obtain cohesion and manage effectively may be seriously
undermined.
Lack of managerial skills and knowledge
One other prominent feature of managers’ concerns was a lack of skills or
knowledge to do their job. In relation to overall managerial support (not just
nursing) and knowledge, the NHS was seen as handling bullying events very
poorly.
Trusts as a whole were mainly regarded as being deficient in the managerial
skills necessary to deal with such complex events effectively.
The study revealed concerns about a lack of training in such skills, and in
managerial and organisational theory for nurses. The nurse’s clinical
management knowledge base was secure enough; but many managers, even at a
senior level, were seen as not possessing sufficient general managerial
training. This situation seems to be being rectified with initiatives such as
LEO,13 and other training schemes, and with the continued recruitment of nurses
onto higher education courses.
Robinson has commented on this situation, complaining that too many nursing
managers get too little preparation too late, and are indeed left to ‘get on
with it’.5
While networking and gaining experience with a wide variety of people is
seen as a particularly important skill, the study reveals that bullying events
strongly mitigate against this, as does the confusion generated by the blurring
of roles boundaries.
Managers similarly indicated an ambivalent attitude towards established
policies and procedures in relation to bullying and harassment; these were
often seen as not effective or deficient and lacking guidance, although again
this was improving. It was felt that such lack of knowledge, senior managerial
support, and lack of clarity on guidance was a contributory factor to the all
too frequent unsatisfactory outcomes of bullying cases.
There was an overall impression that the manager was viewed as ‘all knowledgeable’,
and should not be seen as ‘not coping’. Quite clearly with bullying they are
not, but perhaps this needs to be regarded in a different light before we
condemn nursing managers too harshly as the villains of nursing bullying.
The managers reveal a complex web of interactions and negotiations
reflecting their concerns and actions as they face and attempt to deal with
organisational bullying. But how they deal with such issues has a profound
effect on the workplace, and ultimately, the health of their subordinate
nurses.
Malcolm Lewis is a senior lecturer, department of Postgraduate Medicine and
Health, University of Central Lancashire
References
1. Verbal and Physical Abuse of Nurses, Graydon, J et al (1994), Canadian
Journal of Nursing Administration. 7, 4, pp 70-89
2. Nurses Manage, Hawley, C, Sitwell, J, Robinson, J and Bond, M (1995),
Avebury Publishing, Aldershot
3. Bully off: Recognising and Tackling Workplace Bullying, Clifton, J and
Serdar, H (2000), Russell House Publishing, Lyme Regis
4. Mobbing and Psychological Terror at Workplaces, Leymann, H (1990),
Violence and Victims. 5. pp119-126
5. The Nursing Workforce. In Policy Issues in Nursing, Robinson, K (1992),
(Ed) Robinson, J, Grey, K and Elkan, R, Open University Press, Milton Keynes
6. Understanding Nurses: The Social Psychology of Nursing, Skerrington, S
(Ed) 1984, Chichester Wiley.
7. Reference Groups and Social Control in Human Behaviour and Social
Processes, Shibutani, T (1962), (Ed) Rose, AM
8. A Systematic Summary of Symbolic Interactionism Theory in Human Behaviour
and Social Processes, Rose, AM (1962), Unwin, London
9. Attractiveness of Groups as Function of Self Esteem and Acceptance by
Group, Dittes, JE (1959), Journal of Abnormal and Social Psychology. 59.
pp77-82
10. Bullying in the Professional Workplace: The Effects and Consequences for
Professional Activity, Lewis, M (2002), New Era in Education. 83, 2. World
Education Fellowship
11. Bully in Sight, Field, T (1996), London, Success Unlimited
12. Accounts, Scott, MB and Lyman, SM (1968), American Sociological Review.
33
13. LEO Project (2001), National Nursing Leadership Programme, NHS
Modernisation Agency, DOH
This research is being undertaken within the Department of Healthcare
Studies and with research committee approval at Manchester Metropolitan
University. Support and approval had been given within the Nursing Directorate
and at the Acute Trust used in this study.
Bullying in Nursing: Perceptions of Nurses and Nurse Managers in the UK’s
National Health Service (Lewis 2004) Fig 1. Managerial Perceptions: The main
issues
Managerial issues        Â
1.Parallel processing
2.Comminication
3.
Lack of knowledge/skills
4.
Communication
5.
Demeanour
6.
The manager as a target of bullying
Parallel processing
Comment
Managers essentially inhabit two
worlds; the world of nursing, and that of management. They need to maintain
credibility in both but tend to associate with a preferential reference group,
that of senior managers. This causes tensions in maintaining clinical
credibility while at the same time often being subjected to pressures from more
senior staff. It may have a more dramatic effect on provision of care than if
such pressures effect more junior nurses. In bullying situations the effects
are attenuated.
Comminication
Comment
Communications regarding bullying are often non-existent, with the term
rarely used. Clinical communication is predominant, with staff support centres
around support of clinical practice and supervision. There is lack of
discussion of bullying issues with senior managers. Nurse managers are very
much ‘left to get on with it’. There is a reluctance to report problems both
from fear of censure, and being seen as ‘not being able to cope’. Nurse
managers have limited knowledge of activities in other nursing areas, in
particular of bullying, where such actions which do take place tend to be ‘kept
local’.
Lack of knowledge/skills
Comment
Managers are clear about their role in the mediation of bullying events, in
both supporting the target and speaking to the bully. However, communication
between managers and between other areas is less clear. Bullying events are
often deliberately hidden, and there are difficulties in
terminology/definition. Many nurses and managers who are targets do not
complain, and only identify events as bullying retrospectively.
Communication
Comment
The nurse managers demonstrate a lack of knowledge of bullying and
difficulties in handling such conflict. They attribute this in part to a lack
of knowledge on ‘how to manage’ in a general sense, where they have often had
little or no formal managerial theory or training, particularly in conflict
management. Clinical management of the patients’ condition presents much less
of a problem. There is a perception that NHS management in general is lacking
in its skills to handle bullying events.
Demeanour
Comment
The notion of demeanour applies principally to the bullied target in their
reaction to the bullying event. This therefore is applicable to many of the
managers as they identify themselves as targets of bullying. Demeanour activity
is seen to manifest in two ways. Firstly in the act of ‘demeaning’ ones
abilities, skills, confidence etc, a central bullying tactic, which wears down
the target and creates a negative self image. Targets often blame themselves
for such misfortunes. Coupled with this is a change in demeanour where targets
may act to avoid the conflict situation, by avoiding duty shifts, senior
managers and contact with the perpetrator, and may appear to be more stressed,
losing confidence or ultimately be forced to remove themselves from the
workplace. This is an all too common event in bullying where traumatic effects
can last for extended time periods despite possible resolution of the problem.
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The manager as a target of bullying
Comment
All the managers in the study had either witnessed bullying, or had been
targets of it. There was an admission of using ‘bullying’ methods to get work
done. The main reason for the growth in bullying was identified as increasing
workloads. Managers particularly noted they were prone to being bullied when
they entered a new job or attempted to change the status quo. Such bullying
could be from subordinates as well as senior managers. Managers were in an
unenviable situation of both acting at times as ‘bullies’ while themselves
being targets of it, again adopting ‘dual roles’. This point in itself
questions the veracity of distinct bullying/target personality types as being
the main causal agents for the bullying event. This research reveals that is
predominantly workplace mediated. Â
