Management of disruptive behaviour within nursing work environments: a comprehensive systematic review of the evidence

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1 Management of disruptive behaviour within nursing work environments: a comprehensive systematic review of the evidence Catherine Rogers-Clark RN, BA, MN, PhD 1, Susanne Pearce RN, BN (with distinction),mn,phd Candidate 1 Michelle Cameron RN, BN, MEd 1 1. Australian Centre for Rural and Remote Evidence Based Practice, A Collaborating Centre of the Joanna Briggs Institute Corresponding author: Catherine Rogers-Clark, Australian Centre for Rural and Remote Evidence Based Practice, University of Southern Queensland. rogerscl@usq.edu.au Phone: +61(07) Fax: +61(07) Abstract Background - In an increasingly complex health care environment, where nurses are essential to the health system's capacity to respond to the challenges presented by an ageing population, creating positive work environments is fundamental for nurses, their co-workers, and their patients. Disruptive clinician behaviour, which refers to behaviours such as bullying and physical violence, but also to more subtle behaviours such as withholding vital information or gossiping, can be highly destructive within a work environment. The implications of such behaviours within the nursing workforce specifically, and to the health care system more broadly, are profound. Substantial evidence suggests that the pervasiveness of such behaviours has consequences for recruitment and retention, staff morale, job satisfaction, and staff absenteeism, as well as intra and inter-professional communication and teamwork which can ultimate also affect patient safety. The extent of the problem of disruptive behaviour in the workforce is discussed widely in the literature and nurses as a cohort have been studied extensively, however there has been no systematic review of evidence relating to how to manage these behaviours successfully. Objective- The objective of this systematic review was to appraise and synthesise the best available evidence in relation to interventions which have been successful in managing disruptive clinician behaviour in the nursing work environment. Inclusion criteria Types of participants - The primary participant group of interest for this systematic review includes nurses working in any health care setting; however any other member of the health care team such as medical practitioners or allied health were also considered. Types of intervention(s)/phenomena of interest Any study that explored behavioural, educational, managerial, organisational and personal interventions to manage disruptive behaviours in the health care setting was considered. Types of studies - Studies using quantitative and qualitative methods as well as opinion based papers were considered for this systematic review. Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 615

2 Types of outcomes - Outcomes were assessed in relation to the effect of interventions on patient safety and quality of care, quality of team work and work environment, levels of job satisfaction and nursing staff morale as well as levels of staff retention. Search strategy - Searches were conducted including any published and unpublished material, including grey literature, in the English language. A search of CINAHL, Medline, Medline-in Process, PsychINFO, Emerald and TRIP was undertaken using specifically defined terms and synonyms. Scirus, OpenSIGLE and Google Scholar were also searched. A search of electronic dissertations via Dissertation Abstracts was undertaken. Methodological quality - Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using an appropriate critical appraisal instrument from the System for the Unified Management, Assessment and Review of Information' (SUMARI) developed by JBI. Data Collection - Data was identified as quantitative or qualitative data or opinion based and data extraction tools developed by the Joanna Briggs Institute were used to extract the data, where possible. Where this was not possible, findings were presented in narrative form. Data Synthesis - Data were synthesised according to their methodological approach. Qualitative data were pooled using the QARI instrument and a set of statements were developed that represented a broader overview of a specific aggregation Results - A total of 24 papers, descriptive quantitative, qualitative and textual in approach, were included in the review. The majority of the papers were textual, with a variety of expert opinion provided in relation to managing disruptive clinician behaviour. Conclusions - Comprehensive review of the literature identified that there has been very little research evaluating the effectiveness of interventions to manage disruptive clinician behaviour in nursing, or more broadly within the health care system. A handful of studies involved localised interventions followed by a qualitative evaluation, with useful but not generaliseable findings. These studies emphasised personal, peer and educational approaches to assist those nurses affected by disruptive clinician behaviour within their work teams, but none were related to specific management strategies aimed at the person exhibiting the disruptive behaviour. Most recommendations in the literature were expert opinion. These recommendations emphasised the importance of a clear and consistent organisational approaches to disruptive clinician behaviour. Keywords - disruptive, bullying, incivility, interventions, incivility, management, organisations, nurses, clinicians, health professionals, behaviours. Background Safety and quality thrive in an environment that supports working in teams and respecting other people, regardless of their position in the organisation. Disruptive behaviours that intimidate staff, decrease morale, or increase staff turnover can threaten the safety and quality of care 1. Disruptive clinician behaviour is defined as: "...anything a clinician does that interferes with the orderly conduct of hospital business, from patient care to committee work. This includes behaviour that interferes with the ability of others to effectively Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 616

3 carry out their duties or that undermine the patient's confidence in the hospital or another member of the health care team" 2. Unprofessional staff behaviour was identified as one of the most common causes of staff and family conflict in a 2001 study conducted in the United States. 3 Nursing morale has also been correlated with autonomy, workplace equipment, workplace safety, teamwork, work stress, the physical demand of nursing work, workload, rewards for skills and experience, career prospects, status of nursing and remuneration 3,4. The 2005 Queensland Health Systems Review identified that 'dysfunctional behaviours including bullying, intimidation and a reluctance to share information were frequently reported and confirmed amongst clinical staff in 18 of the 37 Health Service Districts reviewed within Queensland Health 5. The report states that these negative behaviours interfered with the delivery of patient care in a resource constrained environment. Simons 6 identified belittling, punishing, excessive surveillance and exclusion, as victimising behaviours amongst 511 randomly selected registered nurses in the USA. The main finding by Simons was that as these types of behaviours increase, so does the individuals intent to leave the current nursing position 6. Disruptive clinician behaviours have been highlighted as a risk to patient safety by the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) in the United States. Standard LD.3.15 (Leaders create and maintain a culture of safety and quality throughout the hospital) means that American health organisations are now required to demonstrate second yearly completion of assessment of culture using valid and reliable tools and to provide working interventions 7. This standard specifically requires that organisations address disruptive behaviours in the clinical environment. The Queensland Health Foster review recommendation 4.1 articulates that: 'Surveys of workplace culture and staff satisfaction need to be undertaken regularly across the organisation so that all districts can monitor their progress with cultural change through time 5. Emotional outbursts play a negative part in organisational society and a human resource perspective recognises that people work for social and emotional benefits as well as for money 3. Understanding how people communicate and how people are motivated is often based upon an understanding of emotion, as are the behaviours of people. These emotions are the products of socialisation and manipulation and can be termed the emotional climate of an organisation 8,9,10. The Office of Public Service Merit and Equity 11 refers to the organisational climate as being the 'shared perception of what an organisation is like in terms of organisational policies practices, procedures, routines and expected behaviours'. The Office of Public Service has identified that surveys can be employed to measure employee perceptions of a variety of management and leadership practices including working relationships with co-workers and workgroup distress 12. Organisational culture and climate have particular significance in health care because: organisational climate has a strong association with organisational performance (NHS studies demonstrate a strong association between advanced human resource practices, including staff appraisal, teamwork and training and development with lower patient mortality) 1. Staff satisfaction has a very strong positive correlation (0.89) with patient satisfaction 1. Staff satisfaction impacts strongly on absenteeism and turnover 1. This systematic review aims to address the strategies and recommendations available to address disruptive clinician behaviours within the nursing workforce environment. Although a number of strategies and recommendations are already available to assess and provide solutions for disruptive behaviour in nursing, there is a lack of summarised accessible information detailing which of these strategies and recommendations actually work. Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 617

4 Included in this review is the identification of interventions that may enhance positive nurse behaviours. The focus here is to identify interventions and processes that might mitigate negative or dysfunctional behaviours. Within the health care profession generally, strategies such as professional supervision, performance review and education (audit and feedback) 13 have been proposed as a means of addressing all types of clinician behaviours. Various approaches have also been taken to measure emotional and behavioural quotients within organisations. Effective interventions need to be implemented in education, practice and policy to prevent or decrease dysfunctional behaviours amongst employees 14. For example, Fellowes et al 13 critically evaluated all studies that have investigated the effectiveness of different communication skills training techniques for cancer care health care professionals. It was found that there was some evidence that labour-intensive training can have a beneficial impact on health care professional behaviour change 13. As early as the year 2000 the National Summit on Medical Errors and Patient Safety identified that 'bringing about the necessary cultural changes that support team work, acceptance and integration of decision support systems and clinical practice guidelines into health care practices, and avoidance of a 'name and blame' response when errors occur, is vital for positive patient outcomes 1.The ability to detect the presence of disruptive behaviours amongst nursing staff and to address these may therefore have an impact on positive patient outcomes. Patient outcomes are not a focus for this review. The potential for improved patient outcomes as a result of improved staff behaviours should be acknowledged as a potential benefit however. To date, a comprehensive systematic review of the literature is yet to be completed that clarifies or synthesises what specific interventions can enhance supportive clinical behaviours. Inclusion criteria Types of participants This review considered all qualitative and quantitative research that focuses on the management of disruptive clinician behaviours within a nursing workforce environment. Studies involving nurses and other members of the health care team including health administrators, medical practitioners, and allied health workers were included. Types of intervention(s)/phenomena of interest Interventions of interest were quantitative and qualitative nursing and other health professional studies that addressed behavioural/educational/managerial or organisational interventions associated with the effective management of disruptive clinician behaviour. Types of studies Studies that describe successful behavioural, educational or other types of management interventions for disruptive clinician behaviours were included. Opinion-based papers were explored to extract the opinions of respected authorities based upon consensus or experience in the absence of rigorous quantitative and qualitative research studies. Non-English language articles were excluded. Types of outcomes Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 618

5 Outcome measures included measures (quantitative studies) or descriptions (qualitative studies) of the success or otherwise of interventions to manage disruptive clinician behaviour. Outcomes sought included the effect of interventions on patient safety and quality of care, quality of team work, levels of job satisfaction, retention rates of staff and perceptions of the quality of their work environment. Search strategy The search strategy was designed to access published and unpublished material in the English language, including 'grey' data found within research theses and conference proceedings and comprised of three stages: 1 A search of CINAHL, Medline, Medline-In Process, PsychINFO, Emerald and TRIP to identify any relevant keywords contained in the title, abstract and subject descriptors, including MeSH terms. Medline-In process was used to search articles which had not had the cataloguing process completed. 2 Terms identified and the synonyms used by respective databases, were used in an extensive search of the literature. 3 Reference lists and bibliographies of the articles collected from those identified in stage two were searched. The initial search terms were adapted to suit the requirements of each database and terms/descriptors included: -Disruptive -Clinician -Bully* -Mobbing -Nurs* -Behav* -Behavio?r -Strateg* -Interventions -Communication -Morale -Patient Safety -Team Work -Retention -Job Satisfaction -Incivility -Work-related anger -Social climate -Conflict management -Counterproductive work behaviour Articles published in the last 10 year ( ) in English and indexed in the following data bases were searched in order to enhance currency of any recommendations found from the search: Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 619

6 CINAHL Medline Cochrane Library psycinfo Emerald Embase Dissertation Abstracts ERIC Grey Literature Search Scirus Open SIGLE Google Scholar BCEOHRN Full copies of articles identified by the search, and considered to meet the inclusion criteria, based on their title, abstract and subject descriptors, were obtained for data synthesis/analysis. Articles identified through reference lists and bibliographic searches were also considered for data collection based on their title. Two reviewers independently selected articles against the inclusion criteria. Discrepancies in reviewer selection were resolved at a meeting between reviewers prior to selected articles being retrieved. The schema of search strategies and findings from individual databases are detailed in Appendix I. Studies and papers identified by the search are detailed in Appendix II, with those retrieved presented in Appendix III Method of the review Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardised critical appraisal instruments from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information package (SUMARI). The reviewers attempted to group qualitative studies that met the publication criteria into one of the following categories: phenomenological, ethnographic, histographic and grounded theory methodology. However the qualitative studies selected did not typically identify their methodology, nor was a clear methodological framework identified. The majority were simply qualitative, descriptive studies using thematic analysis. Quantitative studies were grouped into one of the following categories: experimental studies; quasi-experimental studies; descriptive studies; descriptivecorrelational studies. The studies were then assessed independently for methodological quality by two reviewers, prior to inclusion in the review using the corresponding checklist from the SUMARI suite developed by the Joanna Briggs Institute. Validity criteria used by the Joanna Briggs Institute (Qari Software, Appendix IV) were used to determine the validity of qualitative studies relating to the outcomes. Opinion-based papers were assessed for inclusion using the JBI Notari tool (Appendix IV). Quantitative studies were assessed for validity using the JBI Mastari tools for experimental and descriptive studies (Appendix IV). Disagreement between reviewers were resolved through discussion with the assistance of a third reviewer where required. Data extraction tools appear as appendices to all articles reviewed. Data Collection Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 620

7 Following methodological assessment, the papers were grouped according to whether they were quantitative, qualitative or opinion-based. Data extraction tools developed by JBI were used to extract salient information from papers within the SUMARI software suite and are detailed in Appendix V. Data extracted from the studies included specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Data Synthesis Qualitative research findings and textual data were pooled using the Qualitative Assessment and Review Instrument (QARI) and JBI -NOTARI. This involved the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories were then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. It was planned that, where possible, data from quantitative studies would be pooled in statistical meta-analysis using the Meta-Analysis of Statistics Assessment and Review Instrument (MAStARI). All results were to be double entered to minimise the risk of data entry error. However, statistical pooling was not possible and hence narrative form was used to present findings. Synthesised findings are presented and discussed in the following sections and a complete list of the findings and conclusions from included studies is presented in Appendix VIII. The credibility of findings was determined using JBI categories which are presented in Appendix IX. Results Description of studies The literature documenting the problem of disruptive clinician behaviour is substantial. An initial search yielded 1038 papers related to one or more aspects of disruptive clinician behaviour, such as workplace incivility, bullying and harassment. However, comparatively few papers were found which addressed the objective of this review, which focuses on solutions to dysfunctional clinician behaviour. A total 87 articles were retrieved and 23 of those served as background material. Only 64 articles were viewed to be relevant to the review topic and objectives, based on the title and abstract (Appendix VI). Of the 64 studies, 40 were expert opinion text, 18 quantitative studies and six qualitative studies. All studies were written in English and originated in the United Kingdom, United States of America, Canada and Australia. These papers were selected from the search strategy for retrieval, further evaluation and methodological assessment. Of the 64 papers, 41 were excluded for a number of reasons following critical appraisal, including lack of congruence to the review objectives. The excluded studies, including the reason(s) for exclusion are listed in Appendix VII. Of these 64 studies, 23 were included in the review. These papers included: Five papers reporting descriptive-correlational studies Four qualitative, interpretive studies Fourteen textual papers Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 621

8 The included papers addressed organisational as well as individual and peer approaches to managing disruptive clinician behaviour. Of the 23 included papers, one originated in Canada, five in Australia, five in the United Kingdom and 12 in the United States of America. The settings under investigation included 11 hospitals and 12 health care settings from a variety of areas such as community health, mental health or medical practices. The primary focus in the papers was on nurses as a single group (15 papers), nurses and doctors (three papers), doctors as a single group (one paper) and health care employees in general (four papers). As the review progressed, it became clear that multiple terms are used to describe the range of behaviours which disrupt the healthy functioning of a nursing team. For clarity and consistency, the term 'disruptive clinician behaviour' was deliberately chosen as the descriptor to encompass the broad range of behaviours which were problematic within a nursing clinical team. However, all 23 papers selected for this review identified their focus was on solutions to workplace incivility, workplace violence, lateral violence, bullying or harassment. Number of studies found and retrieved Number of studies found Number selected for retrieval Methodological quality This review has found very little high quality evidence to address the review question. Of the 23 papers selected for this review, only nine were research articles. Four papers discussed the results of qualitative research 36,43,48,80. Of these, two were descriptive 36,48 and the other two involved interventions designed to assist nurses manage disruptive clinician behaviour 43,80. The five quantitative studies included four surveys 25,38,66,71 and one study which assessed an intervention using a quasi-experimental design 30. Hence, of the nine, only three 30,43,80 were specifically focussed on implementing and evaluating interventions to manage disruptive clinician behaviour. The other six did address interventions to manage disruptive clinician behaviour, but their data was gathered by survey or interviews where nurses and other health professionals were asked to discuss their experiences of disruptive clinician behaviour and their perceptions of what worked or didn't work in managing these behaviours. Hence, there was no evaluative component to assess the effectiveness of the strategies identified by the survey/interview participants. In summary, there is very little, if any, high quality evidence to address the research question for this review, 'What interventions are successful in managing disruptive clinician behaviour in nursing workplaces?' Number of studies included and excluded following critical appraisal Details of included studies can be found in Appendix VI and excluded studies in Appendix VII. QARI Number of studies included Number of studies excluded 4 2 Number of studies included and excluded Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 622

9 NOTARI Number of studies included Number of studies excluded Number of studies included and excluded MASTARI Number of studies included Number of studies excluded 5 13 Results of metasynthesis of qualitative research findings Meta-synthesis of studies included in the review generated two synthesised findings. These synthesised findings were derived from 11 study findings that were subsequently aggregated into four categories. The study findings are listed in Appendix VIII and the QARI view detailing the relationships between study findings, categories and synthesised findings are also presented. The key to the degrees of credibility used below and in Appendix VIII can be found in Appendix IX. Synthesised Findings Organisational approach Organisational approach Building Understanding and Skills The use of cue cards with information about how to manage laterally violent behaviour was beneficial (C) 43 Newly registered nurses felt that being educated about lateral violence was helpful and should be offered to all nurses (U) 43 Comments Building and maintaining a positive work environment Nurses look up to other professionals and value inter-disciplinary teamwork. Nurses may sometime value teamwork over advocating the needs of the patient. Interprofessional relationships with medical staff remain unequal. (C) 36 The subordinate role of women and societal expectations continue to influence nursing's lack of status and recognition. (C) 36 Professional relationships were one of two main issues raised by the action research group. Professional relationships include doctor-nurse, patient-nurse and nursenurse. (C) 80 Staff 'indoctrinated' into the 'rules' of work, as defined by the bullies (C) 48 The included papers provided a variety of discussions about appropriate organisational interventions to address disruptive clinician behaviour. Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 623

10 Personal and peer approaches Personal and peer approaches Mutual Support Personal strategies Nurses fail to support each other, especially graduate nurses and new staff. (C) To change intra and inter-professional relationships, and enhance nurses' status, mutual support, recognition, shared decision making, education and self-awareness are important. (C) 36 Strategies to address the problem and enhance professional relationships (C) 80 Personally confronting the nurse who was being laterally violent was a difficult but successful strategy. (C) 43 Professional identity was the second major issue raised by members of the action research group. (C) 80 Comments Personal and peer approaches emphasised the importance of self and professional development, and mutual support amongst peers Results of metasynthesis of textual data based on opinion Meta-synthesis of text included in the review generated two synthesised findings. These synthesised findings were derived from 51 publication conclusions that were subsequently aggregated into five categories. The study findings are listed in Appendix VIII and the Notari view detailing the relationships between study findings, categories and synthesised findings are also presented. The key to the degrees of credibility used below and in Appendix VIII can be found in Appendix IX. Synthesised Findings Organisational approach Organisational approach Establishing a policy framework Disruptive conduct policy development for medical staff was embedded in a number of steps. Initial engagement with administrators and physician leaders was required to raise organisational approach awareness of the problem. This was further legitimised through the establishment of a committee involving senior physicians and one clinical nurse specialist. 26 (U) Policy was developed with the goals of protecting everyone involved, publicising and acknowledging norms of behaviour and consequences if the behaviour was not followed, and establishing channels to follow with clear steps should the individual want to make a report. 26 (U) Policies should be put into place stating that bullying is not tolerated, and outlining how bullying incidents will be dealt with. 50 (C) A universal code of conduct should be developed for everyone in contact with the hospital which clearly describes those behaviours that are unacceptable. The code should be accompanied by any policies, procedures, or regulations to permit it to serve as grounds for dismissal or termination for violations. 65 (C) Staff members should be required to sign a statement of intent to comply with the code of Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 624

11 practice, which includes an acknowledgement that failure to comply may result in disciplinary actions. 65 (C) The universal code of conduct compliance monitoring system must be complemented by a clear policy of non-retaliation. 65 (C) Staff should have knowledge about specific pieces of workplace legislation about harassment at work that the individual can refer to and discuss with a trade union representative. 68 (C) A 'Dignity at Work Policy' which includes section on harassment, discrimination, violence, and bullying, can highlight the employer's commitment to provide workers with employment that is free from acts of bullying and intimidating behaviour. 70 (C) A universal code of conduct should provide guidance to both clinicians and administrators. 77 (C) Building Understanding and Skills A clearly stated code of conduct and policies and procedures for dealing with violations are prerequisites for developing a positive work environment. 78 (C) Building Understanding and Skills Nurse leaders need to develop policies on bullying in the workplace and conflict resolution mechanisms. 79 (C) Organisational awareness of the policy was enhanced by dissemination to all physicians and an educational program about disruptive behaviours. Nursing staff received professional development training on self-preservation and assertiveness. 26 (U) Occupational health nurses are well positioned through their training to attend to all levels of violence prevention in the workplace through assessment, planning and strategy implementation as well as outcome evaluation. 41 (C) All health care leaders should become aware of the potential for bullying to occur within their organisations, and should work to eliminate it. 50 (C) Staff and management need to educated about bullying, what bullying behaviours look like and how to deal with bullying, both from the standpoint of a target, and as a bystander. 50 (C) Develop an orientation process for new employees and voluntary medical staff to clearly teach the expected behaviours and norms. 58 (C) Every staff member must receive a copy of the code of conduct together with training about the code and attendant behavioural expectations. Training should include guidance on what to do if disruptive behaviour is witnessed. 65 (C) Nurses need to be encouraged to become involved in developing anti-bullying programs that teach the principles of bullying avoidance. 70 (C) Reinforce the organisation's commitment to promoting a caring, professional interpersonal culture by routinely offering in-house training in interpersonal skills as well as newsletters, awards and other incentives that reward outstanding Building and maintaining a positive work environment examples of collaboration. 78 (C) Nurse leaders need to ensure that nursing supervisors receive adequate non-clinical training for their role. 79 (C) Nurse leaders need to provide access to professional development opportunities for all staff. 79 (C) Building and Nurses need to be educated about anger and how to manage it and empowered to act appropriately. 81 (C) A multidisciplinary retentions committee was formed to promote positive work Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 625

12 maintaining a positive work environment environments. 26 (U) To eliminate disruptive behaviour the code of silence needs to be broken. Administrations must go public about the pervasiveness of concerns. To influence change, leaders need to begin by acknowledging the frequency of concerns. 42 (C) Strategies to reduce workplace violence include the assessment of the workplace's level of violence and the development of plans to improve workplace conditions. 41 (C) Violence needs to be stopped before it escalates and this should be the primary focus of any workplace prevention program. Staff have the right to work in a safe environment. 41 (C) Management needs to be committed to zero tolerance of violent behaviours and must empower nurses to no longer accept violence as part of their job. 41 (C) In an organisation with a strong focus upon productivity, promotions may be based upon the achievement of efficiency, with little regard for the means use to achieve the outcome. In this type of environment tolerance and reward of bullying may be closely aligned to achieving outputs or performance targets. 46 (C) Healthcare organisations may need to consider systems in which those responsible for investigating and managing complaints of bullying have no stake in the outcome. In particular, given that managers are reported as common perpetrators of bullying. 46 (C) Cultural audits may enable organisations to learn about the existence and sedimented nature of sub-climates and alliances that perpetuate tolerance of workplace bullying. 46 (C) Organisations need to determine if there are any organisational factors, such as oppressive policies and procedures, or punitive evaluation methods, that inadvertently contribute to bullying, and work to create an environment in which bullying cannot occur. 50 (C) Create and sustain a high-performance work culture that focuses on attaining organisational goals by enabling individuals and groups at all levels to maximise their full potential. 58 (C) Recognise and reward behaviours that demonstrate collaboration, respect, and a high regard for interpersonal ethics. 58 (C) Update job descriptions on the basis of a job analysis and competency development process that focuses on collaboration and team work. 58 (C) Adopt a behaviour-based job interview process to not only select for skills but also for behavioural competencies and a behavioural fit with the culture. 58 (C) Hospitals should implement known best practice designed to improve relationships between members of the health care team, such as SBAR and formal teamwork training. 65 (C) Developing assertiveness in conversational style can help to reduce bullying behaviour. Assertiveness courses may be available to staff where the principles and opportunities to practise will be provided. 68 (C) Nurses need to take ownership and responsibility of the environment they work in and be involved in policy development. Policies should focus on creating a work environment that treats nurses with dignity, respect and fairness. 70 (C) Celebrating positive, bully-free work environments can also decrease bullying behaviours, such as implementing a bullying awareness week at work. 70 (C) Nurse leaders can also decrease bullying by promoting team work and team building among nurses to promote flexibility, sensitivity to the needs of others, and encouragement Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 626

13 of creativity within the group. 70 (C) Expectations for professional behaviour should be outlined explicitly in the institutional policies for good citizenship and reaffirmed both by leaders and each clinician on an annual basis during contract renewal and performance reviews. 77 (C) Offer workplace training and experiences that foster positive relationships. 78 (C) Nurse leaders need to develop more open communication and increased access to senior nursing management to tackle the culture of intimidation. 79 (C) Nurse leaders need to ensure that competency standards refer specifically to managing bullying and that these standards are maintained through an effective performance management system. 79 (C) Comments The included papers provided a variety of discussions about appropriate organisational interventions to address disruptive clinician behaviour. Synthesised finding Personal and peer approaches Personal and peer approaches Mutual Support Personal strategies Any individual who has been bullied should talk about it with approaches a friend or trusted colleague. 68 (C) Nurses need to support each other. In some institutions nurses call a special 'code' when a colleague is being verbally abused: All come to stand with the nurse in support. 81 (C) Maintaining a diary provides a written log of incidents and help to identify triggers to bullying episodes and recognise situations to avoid. It helps to plan and rehearse interventions strategies which may reduce escalation of the problem. 68 (C) Managers need to practice what they preach and get additional support. 78 (C) Nurses need to be aware that they can leave an abusive situation and do not have to remain and endure unacceptable behaviour. 81 (U) Nurse need to resolve never to allow a physician to abuse them in front of a patient. 81 (U) Nurses need to use appropriate channels in the workplace to report incidence of harassment and intimidation. 81 (C) Comments: Personal and peer approaches emphasised the importance of self and professional development, and mutual support amongst peers Results of metasynthesis of quantitative research findings Synthesised Findings Synthesised finding: Organisational approach Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 627

14 Comments: The included papers provided a variety of discussions about appropriate organisational interventions to address disruptive clinician behaviour. Synthesised finding: Personal and peer approaches Comments: Personal and peer approaches emphasised the importance of self and professional development, and mutual support amongst peers Narrative Analysis of Quantitative Findings Workplace support as a moderator of the effects of disruptive clinician behaviour A survey of workplace bullying 66 conducted in the UK with community nurses employed by the NHS explored, amongst other things, whether workplace support could moderate the ill effects of bullying nurses, allied health professionals, administration staff and medical practitioners participated in the survey. 396 of the participants (36%) were registered or enrolled nurses. Nurses were significantly more likely to have experienced bullying than the other participant groups in the survey, and reported significantly more types of bullying than other staff. Four two-way analyses of variance assessed the moderating effects of a supportive work environment on job satisfaction, propensity to leave, anxiety and depression. Nurses who reported being bullied, and reported good workplace support, had significantly higher scores for job satisfaction and significantly lower scores on the depression and propensity to leave scales than nurses who were bullied but reported poor workplace support. Table 1. Results of two-way analysis of variance Outcome Main effect of bullying Main effect of support Interaction effect Job Satisfaction F (1, 389) = 22.3*** F (1, 389) = 50.8 *** F (1, 389) = 4.1** Anxiety F (1, 384) = 25.0*** F (1, 384) = 18.6 *** F (1, 384) = 0.1 NS Depression F (1, 383) = 25.3 *** F (1, 383) = 31.1 *** F (1, 383) = 4.9 * Propensity to leave F (1, 389) = 8.1 ** F (1, 389) = 24.0 *** F (1, 389) = 4.3* NS: not significant, * p <.05, ** p <.01, *** p<.001 Deans 38 investigated the relationship between occupational violence, organisational support and nurses perceptions of their professional competence using data from a random sample survey of 380 registered nurses in Victoria, Australia. Occupational violence in this study included verbal and physical aggression from patients, doctors and nurses. T-test analysis identified that occupational violence significantly affected nurses perceived professional competence [t(df=382) = 3.05, p < 0.002]. Regression analysis revealed significant interaction between organisational support and occupational violence, with organisational support providing a moderating effect on the relationships between occupational violence and professional competence. Participants indicated that organisational support was mostly provided by nursing colleagues, with doctors providing little support. Nurse-Doctor relationships A survey of 1200 nurses, doctors and health executives in a national network of community owned hospitals and health care services, on the West Coast of the United States 71, revealed that nurses morale was strongly affected by the quality of daily interactions between nurses and doctors. The study involved a convenience sample survey. 720 of the 1200 participants were nurses. The 24 item survey involved questions requiring yes/no, Likert-type or open-ended responses. Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 628

15 One open-ended question in the survey asked participants to suggest strategies for improving nursedoctor relationships. 161 of the 556 nurse participants (29%) suggested that improved opportunities for collaboration and communication would be most helpful. 131 nurses (24%) indicated that education and training for nurses and doctors about how to build more positive working relationships would be helpful. 38 nurses (6.8%) identified that more open forums and group discussions were necessary, and 37 (6.7%) felt that both nurses and doctors needed to accept more accountability for their actions. Conflict Management Training to assist with difficulties in nurse/doctor relationships A small study 30, using a quasi-experimental design, explored nurses perceptions of collaboration with their medical colleagues before and after conflict management training. The study was set in a 372 bed private hospital in Southern California. Eighteen registered nurses were in the control group (no conflict management training) and nine were in the experimental group. The nurses in the control group worked on the telemetry unit within the same hospital, and had access to the same medical practitioners as the nurses in the experimental group. The conflict management training was based on a view that conflict begins with misunderstandings and defensiveness. A psychodynamic approach (focus on changing thinking) underpinned the training. Participants in both the experimental and control groups completed the Collaborative Behaviour Scale (CBS), a twenty item 4-point Likert-type scale, with established reliability and validity. Participants completed the scale at baseline and at three months post-test. There were no significant differences between the control and experimental groups on the CBS at baseline (p>.05) and at post-test, F (1,27) = 1.47, p =.236. The intervention was not effective in enhancing nurses perceptions of collaboration and conflict management with the medical practitioners working in their unit. Indeed, scores on the CBS for the experimental group were worse at post-test than at pre-test, though not significantly. Of note was that only nurses were involved in the conflict management training. practitioners on the unit did not participate. The medical Actions to deal with bullying and harassment A large survey in the UK, commissioned by the Royal College of Nursing (RCN), explored nurses wellbeing and working lives RCN members from England, Northern Ireland, Scotland and Wales were requested to participate useable responses were received. The survey included questions on bullying and harassment. One question asked what action was taken by the participant when bullying or harassment occurred. The value of these results is that nurses reported what had worked for them rather than speculating on what might work, as in the 71 Table 2: Action taken to deal with bullying/harassment and how situation changed as a result percentages How situation changed - % Action taken % Unchanged Got worse Improved Told a colleague Told manager Told another more senior member of staff Spoke to the bully/harasser about the problem Sought help from the RCN Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 629

16 Made an informal complaint Made a formal complaint Sought a change in work situation to get away from person causing problem Resigned/left my job Sought other support from employer Sought other support from outside workplace No action taken so far The data suggests that, other than leaving the work environment, seeking support outside the workplace was the most successful strategy and effective for more nurses than seeking assistance from employers, managers, colleagues or their professional organisation (RCN). Speaking to the bully/harasser about the problem was successful for 35% of the participants; however 20% reported that this action caused the situation to get worse. Discussion Work-related pressure on nurses and nursing work teams is likely to be maintained or even escalate as the health care system attempts to respond to the increased demand which is an inevitable consequence of an ageing population. Functional, productive and happy work teams are important for nursing job satisfaction and the recruitment and retention of nurses as well as patient outcomes. There is ample evidence within the literature that disruptive clinician behaviour is a substantial problem for the profession, and threatens good outcomes for nurses and their patients. This behaviour can come from within the profession (nurse-nurse) or between members of different professional groups (for example doctor-nurse). There is also substantial evidence that this problem, whether it is labelled as lateral violence, workplace violence, workplace incivility, bullying or harassment, creates significant and ongoing personal suffering for those affected. There is a clear need, then, to manage the problem of disruptive clinician behaviour. However, to date there has been no systematic review to identify interventions which are successful in managing disruptive clinician behaviour. From early in the protocol development, it was evident that there was a substantial body of literature documenting the nature and extent of the problem, but a disappointing lack of evidence in relation to the effectiveness or otherwise of interventions to address disruptive clinician behaviour. Hence this review has taken a deliberately broad approach. Incorporating methodologies embedded in the SUMARI package, this review was able to consider interpretive, critical and textual data to ensure that all available, good quality literature was able to be incorporated. Unfortunately, as already noted, very little literature is available in relation to managing the problem of disruptive clinician behaviour. Recommendations for what might be useful strategies were frequently listed at the end of papers which were focused on identifying and describing the problem, but a clear focus on specific evaluation of the effectiveness of management solutions to the problem was rare. Meta-analysis of the five quantitative papers was not possible, with only one of these 30 specifically assessing an intervention. This limits the overall results of the review. Critical appraisal and synthesis of the remaining 18 papers was completed using methodologies within JBI-QARI and JBI-NOTARI. This resulted in three syntheses related to interventions which are successful in responding to disruptive clinician behaviour. The papers in this review considered successful strategies for Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 630

17 managing disruptive clinician behaviour using two main approaches. The first involved implementing and evaluating an intervention. Only three of the nine research papers in this review took this approach, and all involved a localised intervention and small numbers of participants. The second approach, used in the remaining six research papers, was to survey nurses and asks them to identify strategies which they believed had been or would be effective. These papers were not focused specifically on an intervention focus, and hence these questions were generally part of a broader study which looked at the problems associated with disruptive clinician behaviour. The results of this review, limited though they are because of the limited literature addressing the review topic, do provide some suggestions about interventions which may be of use in managing this pervasive problem. An appropriate organisational focus on the problem is essential. Disruptive clinician behaviour flourishes in work environments where such behaviour is ignored, tolerated or even rewarded. Zero tolerance policies, which clearly identify what constitutes disruptive clinician behaviour (often using the titles of bullying and harassment), are required, accompanied by clear strategies for managing the problem and possible consequences if the behaviour does not cease. An organisational commitment to implementing the policy is just as important and identified strategies should be consistently adhered to. This is a critical issue in health care, where at times disruptive behaviour is excused because the clinician is highly competent and seen as effective in his/her role, or where different rules and/or expectations apply to different professionals. Bullying behaviours may actually be rewarded if the perpetrator is seen as someone who can 'get results'. Dealing with managers who are displaying disruptive behaviours is seen as crucial yet challenging. Very often, organisations believe they have handled the problem because they have introduced a zero tolerance policy, and charged managers with the responsibility for implementing it. However, if the disruptive behaviour is pervasive within the management group, this is clearly an inappropriate strategy. Hence, it is important that the organisational approach does not assume that the disruptive behaviour occurs vertically and that managers are not engaged in such behaviour. One paper in particular 48 identified that disruptive clinician behaviour may be a group behaviour rather than an individual response. That is, groups of clinicians may form informal alliances and operate together to achieve their goals. These goals may include maintenance of the status quo, or of their positions of power within a work team. This then raises issues of workplace culture, as distinct from a perspective which sees isolated individuals as the problem. Another important aspect of an organisational approach is to build and sustain a positive work environment. Strengthening interprofessional relationships were seen as important for minimising disruptive clinician behaviour, particularly in relationships traditionally marked by unequal power relationships, such as those between nurses and medical practitioners. The creation of multidisciplinary committee to promote positive work environments were suggested a number of times. Formal teamwork training was seen to be important, as was identifying and rewarding positive behaviours. Open communication between staff at different levels within the organisation makes it possible for disruptive clinician behaviour to be reported when it occurs. A range of personal or peer responses to disruptive behaviour were also identified. The three intervention studies fitted into this category. One focused on teaching conflict resolution skills to nurses, to help them manage disruptive behaviour within their interdisciplinary team 30. A second assessed the effectiveness of cognitive rehearsal as a skill newly graduated nurses could use to help them deal with lateral violence 43. The third intervention study involved the use of reflection on practice issues in an action research group involving registered nurses, where the nurses chose to focus their efforts on dysfunctional nurse-nurse relationships. None of these studies addressed the disruptive behaviour itself. Instead, their focus was on helping Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 631

18 nurses manage the disruptive behaviour of their colleagues. There was, then, no focus on the perpetrators. Conclusion Nurses constitute the largest group of professional in the health care arena and their contribution to the health and wellbeing of society is well recognised and, within the community at least, highly valued. Nursing is a profession which is intrinsically challenging. Increasing workloads, the pace of change, more focus on budgetary control, accountability and outcomes, and a shortage of skilled staff within the health care system create substantial levels of stress for nurses who are already fully occupied on a daily basis in responding to the complex needs of patients and their families. In this environment, dealing with team members who engage in disruptive behaviours is an added and unnecessary burden. The evidence is that this burden is felt on personal, professional and systemic levels. Disruptive clinician behaviour is personally damaging to the nurses who have to deal with it in their work teams, but is also damaging to the profession of nursing which seeks to improve its image, demonstrate the positive outcomes of nursing work, and recruit and retain high quality graduates. Finally, disruptive clinician behaviour is damaging to the effective functioning and outputs of the health care system. It is a cause of staff dissatisfaction, higher turnover and is linked to poor outcomes in relation to patient safety. Despite recognition of the wide implications of this problem, to date very few studies have been undertaken to systematically assess the effectiveness of intervention strategies. Hence, there is little evidence to answer the research question guiding this systematic review, which asks what interventions are successful in managing disruptive clinician behaviour. Implications for practice Health care organisations need to make the creation of healthy work environments a priority, as nurses and indeed any health professionals cannot and do not work effectively in an environment that is unsupportive and toxic. The extent of the problem is perhaps best demonstrated by the proposal that nursing students need specific training in how to manage the horizontal violence they are bound to encounter in their professional lives. This is a telling acknowledgement that the profession is well aware of the problem but has not been able to address it successfully. There is clear evidence that disruptive clinician behaviour reduces the quality of communication within a team and hence threatens patient safety, as well as making the workplace unpleasant and at times unbearable. Given the evidence documenting the extent of disruptive clinician behaviour, and its consequences, effectively addressing the issue of disruptive behaviour in nursing workplaces is critically important in achieving a healthy work environment. This is, however, a challenging task when there is little empirical evidence to support decision-making about appropriate strategies to implement. The evidence that is available documents some success in helping nurses to manage disruptive behaviour from their colleagues. However, this is a reactive approach and does little if anything to address the Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 632

19 problem itself. The expert opinion literature suggests that a whole or organisation approach is required, with relevant policy and process developed and implemented. Of critical importance is that the policy must be applied to all staff regardless of their seniority within the organisation, their length of service or their competence as clinicians. Consideration needs to be given to how to manage managers who themselves engage in disruptive behaviour, given that it is generally managers who are responsible for the policy implementation. In health care settings where ongoing institutional change is the norm, rewarding managers and significant other players for getting results at all costs, even if that is at the expense of nurses morale and job satisfaction, encourages bullying and is ultimately unproductive. Training is important, as is including a focus on identifying and rewarding positive behaviour which supports happy, positive work environments. Implications for research This systematic review has demonstrated a clear and urgent need for research which implements and evaluates strategies specifically designed to respond to the problem of disruptive clinician behaviour. Due to the limited evidence currently available on what is the current best practice to manage disruptive behaviours in the health care setting, there is an urgent need for researchers and health care leaders to use action research and other relevant methodologies to develop implement and evaluate strategies to manage disruptive clinician behaviour. Conflict of Interest No conflict of interest could be identified. Acknowledgements We would like to acknowledge Professor Gerry Fogarty from the University of Southern Queensland and Ms Linda Hardy from Queensland Health for their assistance in reviewing this work. References 1 Bennet, Margaret, Priorities for Nursing and Midwifery Research, Nursing & Nursing Education Taskforce, Brown, R.B. & Brooks, I, Emotion at work: Identifying the emotional climate of night nursing, Journal of Management in Medicine, 16: Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 633

20 3 Cortina, L.M. & Magley, V.J. & Hunter Williams, J. & Day Langhout, R., Incivility in the workplace: incidence and impact, Journal of Occupational Health Psychology, 6: Felblinger, D. M., Incivility and bullying in the workplace and nurses' shame responses, JOGNN, 37: Fellowes, D. & Wilkinson, S. & Moore, P., Communication skills training for health care professionals working with cancer patients, their families and/or carers, The Cochrane Database of Systematic Reviews , : Fineman, S. (ed), Emotions in Organisations, Sage Publications, London, Hutchinson, M. & Vickers, M. & Jackson, D. & Wilkes, L., Workplace bullying in nursing: towards a more critical organisational perspective, Nursing Inquiry, 13: Hutton, S.A., Workplace incivility, JONA: The Journal of Nursing Administration, 36: Joint Commission on Accreditation of Healthcare Organisations, Proposed Standard for Disruptive Behaviour-Hospital, MacIntosh, J., Tackling work place bullying, Issues in Mental Health Nursing, 27: McGee, D. & Shigemitsu, H. & Henig, N. & Raffin, T., Conflict over communication and unprofessional staff behaviour: A source of dissatisfaction during the withdrawal of care? Critical Care Medicine, 28: McIIduff, E. & Coghlan, D., Understanding and contending with passive-aggressive behaviour in teams and organizations, Journal of Managerial Psychology, 15: Office of Public Service Merit and Equity (State of Queensland), Quality public service workplaces information paper 8, Organisation Health: Office of the Public Service, A focus on people: A workforce management strategy for the Queensland public sector, Brisbane, Queensland, Pearson A, Balancing the evidence: incorporating the synthesis of qualitative data into systematic reviews, JBI Reports, : Pearson, C.M. & Andersson, L.M. & Wegner, J., When workers flout convention: A study of workplace incivility, Human Relations, 54: Queensland Health, Workplace culture and leadership, : Queensland Health, Queensland Health Systems Review. Final Report, : Rayner, C. & Hoel, H. & Cooper, C.L., Workplace Bullying. What we know, who is to blame, and what we do?, Rime, B. & Mesquite, B. & Philpott, P. & Boca, S., Beyond the emotional event: six studies on the social sharing of emotion, Journal of Cognition and Emotion, 5: Roberts, S.J. & Demarco, R. & Griffin, M., The effect of group behaviours on the culture of the nursing workplace: a review of the evidence and interventions for change, Journal of Nursing Management, 0: Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 634

21 22 Rosenstein, A. H. & O'Daniel, M., Disruptive Behaviour & Clinical Outcomes: Perceptions of Nurses & Physicians: Nurses, physicians, and administrators say that clinicians' disruptive behaviour has negative effects on clinical outcomes. Nursing Management, 36: Simons, S.R., Workplace bullying experienced by nurses newly licensed in Massachusetts, Dissertation Abstracts International: Section B: The Science and Engineering, 67: Appendix I: Search Strategy Schema of search strategies and references for inclusion and exclusion Table1: Initial search based on key terms/descriptors Database Number of Articles CINAHL 478 Medline 63 Cochrane Library 11 psyche Info 21 Emerald 34 Embase 196 Dissertation Abstracts 5 Eric 5 Grey Literature 225 Total 1038 Table 2: Final data selection Type of Studies Total Excluded Included Quantitative Studies Qualitative Studies Expert Opinion Total Appendix II: Search Results 1 Bennet, Margaret, Priorities for Nursing and Midwifery Research, Nursing & Nursing Education Taskforce, Brown, R.B. & Brooks, I., Emotion at work: Identifying the emotional climate of night nursing, Journal of Management in Medicine, 16: Cortina, L.M. & Magley, V.J. & Hunter Williams, J. & Day Langhout, R., Incivility in the workplace: incidence and impact, Journal of Occupational Health Psychology, 6: Felblinger, D. M., Incivility and bullying in the workplace and nurses' shame responses, JOGNN, 37: Fellowes, D. & Wilkinson, S. & Moore, P., Communication skills training for health care professionals working with cancer patients, their families and/or carers, The Cochrane Database of Systematic Reviews , : Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 635

22 6 Fineman, S. (ed), Emotions in Organisations, Sage Publications, London, : Hutchinson, M. & Vickers, M. & Jackson, D. & Wilkes, L., Workplace bullying in nursing: towards a more critical organisational perspective, Nursing Inquiry, 13: Hutton, S.A., Workplace incivility, JONA: The Journal of Nursing Administration, 36: Joint Commission on Accreditation of Healthcare Organisations, Proposed Standard for Disruptive Behaviour-Hospital, : MacIntosh, J., Tackling work place bullying, Issues in Mental Health Nursing, 27: McGee, D. & Shigemitsu, H. & Henig, N. & Raffin, T., Conflict over communication and unprofesional staff behaviour: A source of dissatisfaction during the withdrawal of care?, Critical Care Medicine, 28: McIIduff, E. & Coghlan, D., Understanding and contending with passive-aggressive behaviour in teams and organizations, Journal of Managerial Psychology, 15: Office of Public Service Merit and Equity (State of Queensland), Quality public service workplaces information paper 8, Organisation Health, Office of the Public Service, A focus on people: A workforce management strategy for the Queensland public sector, Brisbane, Queensland,: Pearson A, Balancing the evidence: incorporating the synthesis of qualitative data into systematic reviews, JBI Reports,: Pearson, C.M. & Andersson, L.M. & Wegner, J., When workers flout convention: A study of workplace incivility, Human Relations, 54: Queensland Health, Workplace culture and leadership, Queensland Health, Queensland Health Systems Review. Final Report, Rayner, C. & Hoel, H. & Cooper, C.L., Workplace Bullying. What we know, who is to blame, and what wer do? Rime, B. & Mesquite, B. & Philpott, P. & Boca, S., Beyond the emotional event: six studies on the social sharing of emotion, Journal of Cognition and Emotion, 5: Roberts, S.J. & Demarco, R. & Griffin, M., The effect of group behaviours on the culture of the nursing workplace: a review of the evidence and interventions for change, Journal of Nursing Management, 0: Rosenstein, A. H. & O'Daniel, M., Disruptive Behaviour & Clinical Outcomes: Perceptions of Nurses & Physicians: Nurses, physicians, and administrators say that clinicians' disruptive behaviour has negative effects on clinical outcomes. Nursing Management, 36: Simons, S.R., Workplace bullying experienced by nurses newly licensed in Massachusetts, Dissertation Abstracts International: Section B: The Science and Engineering, 67: Antecol, H. & Cobb-Clark, D., Does sexual harassment training change attitudes? A view from the Federal level, Social Science Quarterly, 84: Ball, J. & Pike, G., At breaking point? A survey of the wellbeing and working lives of nurses in 2005, PTRC, University of Leeds, 0: Barnsteiner, J.H. & Madigan, C., Instituting a disruptive conduct policy for medical staff,aacn Clinical Issues, 12: Beech, B., Beating the bullies, Emergency Nurse, 12: Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 636

23 28 Befar, K.J & Peterson, R.S. & Mannix, E.A. & Trochim, M.K., The critical role of conflict resolution in teams: a close look at the links between conflict type, conflict management strategies, and team outcomes, Journal of Applied Psychology, 93: Beyea, Suzanne C., Intimidation in health care settings and patient safety, AORN Journal, 80: Boone, B. N.& King, M. L. et al., Conflict management training and nurse-physician collaborative behaviours., Journal for Nurses in Staff Development : JNSD: Official journal of the National Nursing Staff Development Organization, 24: Brennan, W. I'm talking to you! Managing bullying and harassment in the workplace, Emergency nurse: the journal of the RCN Accident and Emergency Nursing Association, 7: Broome, B. A., Dealing with sharks and bullies in the workplace, ABNF Journal, 19: Cassirer, C.D. & Anderson, D. & Hanson, S., Abusive behaviour in the healthcare workplace, Creative Nursing, 8: Corr, Margaret, Reducing occupational stress in intensive care, Nursing in Critical Care,5: Crawford, N., Conundrums and confusion in organisations: the etymology of the word 'bully', International Journal of Manpower, 20: Daisiki, I., Changing nurses' dis-empowering relationship patterns, Journal of Advanced Nursing, 48: DeChurch, L. A., K. L. Hamilton, et al., Effects of conflict management strategies on perceptions of intragroup conflict., Group Dynamics: Theory, Research and Practice,11: Deans, C., Nurses and occupational violence: the role of organisational support in moderating professional competence., Australian Journal of Advanced Nursing, 22: Everton, W.J. & Jolton, J. A. & Mastrangelo, P.M., Be nice and fair or else: understanding reasons for employees' deviant behaviours, Journal of Management Development, 26: Friesen, M.A & Hughes, R.G. & Zorn, M., Communication: patient safety and the nursing work environment, Nebraska Nurse, 40: Gallant-Roman, M. A., Strategies and Tools to Reduce Workplace Violence, AAOHN Journal, 56: Grenny, J., Crucial conversations: the most potent force for eliminating disruptive behaviour, Critical care nursing quarterly, 32: Griffin, M., Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses, Journal of Continuing Education in Nursing, 35: Hegney, D. & Eley, R. & Plank, A. & Buikstra, E. & Parker, V., Workforce issues in nursing in Queensland: 2001 and 2004, Journal of Clinical Nursing, 15: Hendel, T. & Fish, M. & Galon, V., Leadership style and choices of strategy in conflict management among Israeli nurse managers in general hospitals, Journal of Nursing Management, 13: Hutchinson, M. & Jackson, D. & Wilkes, L. & Vickers. M.H, A new model of bullying in the nursing workplace, Advances in Nursing Science, 31:E60-E Hutchinson, M. & Vickers, M.H. & Jackson, D. & Wilkes, L., "I'm gonna do what I wanna do."organisational change as a legitimized vehicle for bullies, Health Care Management Review, 30: Hutchinson, M. & Vickers, M.H. & Jackson, D. & Wilkes, L., 'They stand you in a corner, you are not to speak: nurses tell of abusive indoctrination in work teams dominated by bullies, Contemporary Nurse, 21: Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 637

24 49 Jackson, D.,& Firtko, A. et al., Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review., Journal of Advanced Nursing, 60: Johnson, S.L., International perspectives on workplace bullying among nurses: a review, International ursing Review, 56: Judkins, S. & Reid, B. et al., Hardiness training among nurse managers: building a healthy workplace., Journal of continuing education in nursing, 37: Kelloway, E.K. & Day, A. L, Building healthy workplaces: What we know so far, Canadian Journal of Behavioural Science, 37: Leiper, J., Nurse against nurse: how to stop horizontal violence, Nursing, 35: Lewis, M.A., Nurse bullying: organizational considerations in the maintenance and perpetration of health care bullying cultures, Journal of Nursing Management, 14: Lewis, T., What must we do about lateral violence?, New Mexico Nurse, 53: ] 56 Liefooghe, A. P.D. & Olafsson, R., "Scientists" and "amateurs": mapping the bullying domain, International Journal of Manpower, 20: Lim, S. & Cortina, L. M & Magley, V.J., Personal and workgroup incivility: Impact on work and health outcomes, Journal of Applied Psychology, 93: Martin, W. F., Is your hospital safe? Disruptive behaviour and workplace bullying, Hospital Topics, 86: McGillis Hall, L. & Doran, D. & Pink, L., Outcomes of Interventions to improve hospital nursing work environments, JONA, 38: McLemore, M., Workplace aggression: beginning a dialogue, Clinical Journal of Oncology Nursing, 10: Olsen, B. J., D. L. Neslon, et al., Managing aggression in organizations: what leaders must know, Leadership and Organization Development Journal, 27: Pearson, C. M. and C. L. Porath, On the nature, consequences and remedies of workplace incivility: No time for, The Academy of Management Executive, 19: Pearson, C. M., & Andersson, L.M. et al., Assessing and attacking workplace incivility., Organizational Dynamics, 29: Poilpot-Rocaboy, G. & Winter, R., Combating psychological harassment in the workplace: processes for management interventions, International Employment Relations Review, 13: Porto, G. and R. Lauve, Disruptive clinician behaviour: A persistent threat to patient safety., Patient Safety and Quality Healthcare., 29: Quine, L., Workplace bullying in nurses, Journal of Health Psychology, 6: Ramos, M.C., Eliminate destructive behaviours through example and evidence, Nursing Management, 37: Randle, J. & Stevenson, K. et al, Reducing workplace bullying in healthcare organisations, Nursing Standard, 21: Rayner, C., From research to implementation: finding leverage for prevention, International Journal of Manpower, 20: Rocker, C.F., Addressing nurse-to-nurse bullying to promote nurse retention, Online Journal of Issues in Nursing, 13: Rosenstein, Alan H., Nurse-Physician relationships: Impact on nurse satisfaction and retention, AJN, 102: Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 638

25 72 Rutherford, A, & Rissel, C., A survey of workplace bullying in a health sector organisation, Australian Health Review, 28: Salin, D., Organisational responses to workplace harassment., Personnel Review, 38: Sheehan, Michael, Workplace bullying: responding with some emotional intelligence, International Journal of Manpower, 20: Sheehan, Michael & Barker, M. & Rayner, C., Applying strategies for dealing with workplace bullying, International Journal of Manpower, 20: Shuttleworth, A., Managing workplace stress: how training can help, Industrial and Commercial Training, 36: Simpson, K. R., Disruptive Clinician Behaviour, MCN: The American Journal of Maternal Child Nursing, 32: Sotile, W.M. & Sotile, M. O., How to shape positive relationships in medical practices and hospitals, Physician Executive, 25: Stevens, S., From the field. Nursing workforce retention: challenging a bullying culture: how nurses in one Australian hospital confronted intimidation of and by nurses and took steps to remedy it., Health Affairs, 21: Taylor, B., Identifying and transforming dysfunctional nurse-nurse relationships through reflective practice and action research., International journal of nursing practice, 7: Thomas, S. P., Anger: The mismanaged emotion, MEDSURG Nursing, 12: Townend, A, Understanding and addressing bullying in the workplace, Industrial and Commercial Training, 40: Van Fleet, D.D. & Griffin, R.W., Dysfunctional organization culture: The role of leadership in motivating dysfunctional work behaviours, Journal of Managerial Psychology, 21: Weiss, Barbara, Balancing act. Making it work with difficult people, RN, 68: Williams, R., Capturing the moment, Nursing Management, 14: Woelfle, C.Y. & McCaffrey, R., Nurse on Nurse, Nursing Forum, 42: Zwarenstein, M. B. W., Interventions to promote collaboration between nurses and doctors, Cochrane Database Systematic Reviews, : Appendix III: Studies selected for retrieval 1 Bennet, Margaret, Priorities for Nursing and Midwifery Research, Nursing & Nursing Education Taskforce, : Brown, R.B. & Brooks, I., Emotion at work: Identifying the emotional climate of night nursing, Journal of Management in Medicine, 16: Cortina, L.M. & Magley, V.J. & Hunter Williams, J. & Day Langhout, R., Incivility in the workplace: incidence and impact, Journal of Occupational Health Psychology, 6: Felblinger, D. M., Incivility and bullying in the workplace and nurses' shame responses, JOGNN, 37: Fellowes, D. & Wilkinson, S. & Moore, P., Communication skills training for health care professionals working with cancer patients, their families and/or carers, The Cochrane Database of Systematic Reviews , : Fineman, S. (ed), Emotions in Organisations, Sage Publications, London, : Hutchinson, M. & Vickers, M. & Jackson, D. & Wilkes, L., Workplace bullying in nursing: towards a more critical organisational perspective, Nursing Inquiry, 13: Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 639

26 8 Hutton, S.A., Workplace incivility, JONA: The Journal of Nursing Administration, 36: Joint Commission on Accreditation of Healthcare Organisations, Proposed Standard for Disruptive Behaviour-Hospital, : MacIntosh, J., Tackling work place bullying, Issues in Mental Health Nursing, 27: McGee, D. & Shigemitsu, H. & Henig, N. & Raffin, T., Conflict over communication and unprofessional staff behaviour: A source of dissatisfaction during the withdrawal of care?, Critical Care Medicine, 28: McIIduff, E. & Coghlan, D., Understanding and contending with passive-aggressive behaviour in teams and organizations, Journal of Managerial Psychology, 15: Office of Public Service Merit and Equity (State of Queensland), Quality public service workplaces information paper 8, Organisation Health, : Office of the Public Service, A focus on people: A workforce management strategy for the Queensland public sector, Brisbane, Queensland, : Pearson A, Balancing the evidence: incorporating the synthesis of qualitative data into systematic reviews, JBI Reports, : Pearson, C.M. & Andersson, L.M. & Wegner, J., When workers flout convention: A study of workplace incivility, Human Relations, 54: Queensland Health, Workplace culture and leadership, : Queensland Health, Queensland Health Systems Review. Final Report, : Rayner, C. & Hoel, H. & Cooper, C.L., Workplace Bullying. What we know, who is to blame, and what we do?,, : Rime, B. & Mesquite, B. & Philpott, P. & Boca, S., Beyond the emotional event: six studies on the social sharing of emotion, Journal of Cognition and Emotion, 5: Roberts, S.J. & Demarco, R. & Griffin, M., The effect of group behaviours on the culture of the nursing workplace: a review of the evidence and interventions for change, Journal of Nursing Management, 0: Rosenstein, A. H. & O'Daniel, M., Disruptive Behaviour & Clinical Outcomes: Perceptions of Nurses & Physicians: Nurses, physicians, and administrators say that clinicians' disruptive behaviour has negative effects on clinical outcomes., Nursing Management, 36: Simons, S.R., Workplace bullying experienced by nurses newly licensed in Massachusetts, Dissertation Abstracts International: Section B: The Science and Engineering, 67: Antecol, H. & Cobb-Clark, D., Does sexual harassment training change attitudes? A view from the Federal level, Social Science Quarterly, 84: Ball, J. & Pike, G., At breaking point? A survey of the wellbeing and working lives of nurses in 2005, PTRC, University of Leeds, 0: Barnsteiner, J.H. & Madigan, C., Instituting a disruptive conduct policy for medical staff,aacn Clinical Issues, 12: Beech, B., Beating the bullies, Emergency Nurse, 12: Befar, K.J & Peterson, R.S. & Mannix, E.A. & Trochim, M.K., The critical role of conflict resolution in teams: a close look at the links between conflict type, conflict management strategies, and team outcomes, Journal of Applied Psychology, 93: Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 640

27 29 Beyea, Suzanne C., Intimidation in health care settings and patient safety, AORN Journal 80: Boone, B. N. & King, M. L. et al., Conflict management training and nurse-physician collaborative behaviours., Journal for Nurses in Staff Development : JNSD: Official journal of the National Nursing Staff Development Organization, 24: Brennan, W., I'm talking to you! Managing bullying and harassment in the workplace, Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association, 7: Broome, B. A., Dealing with sharks and bullies in the workplace, ABNF Journal, 19: Cassirer, C.D. & Anderson, D. & Hanson, S., Abusive behaviour in the healthcare workplace, Creative Nursing, 8: Corr, Margaret, Reducing occupational stress in intensive care, Nursing in Critical Care, 5: Crawford, N., Conundrums and confusion in organisations: the etymology of the word 'bully', International Journal of Manpower, 20: Daisiki, I., Changing nurses' dis-empowering relationship patterns, Journal of Advanced Nursing, 48: DeChurch, L. A., K. L. Hamilton, et al., Effects of conflict management strategies on perceptions of intra-group conflict., Group Dynamics: Theory, Research and Practice,11: Deans, C., Nurses and occupational violence: the role of organisational support in moderating professional competence., Australian Journal of Advanced Nursing, 22: Everton, W.J. & Jolton, J. A. & Mastrangelo, P.M., Be nice and fair or else: understanding reasons for employees' deviant behaviours, Journal of Management Development, 26: Friesen, M.A & Hughes, R.G. & Zorn, M., Communication: patient safety and the nursing work environment, Nebraska Nurse, 40: Gallant-Roman, M. A., Strategies and Tools to Reduce Workplace Violence., AAOHN Journal, 56: Grenny, J., Crucial conversations: the most potent force for eliminating disruptive behaviour, Critical care nursing quarterly, 32: Griffin, M., Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses, Journal of Continuing Education in Nursing, 35: Hegney, D. & Eley, R. & Plank, A. & Buikstra, E. & Parker, V., Workforce issues in nursing in Queensland: 2001 and 2004, Journal of Clinical Nursing, 15: Hendel, T. & Fish, M. & Galon, V., Leadership style and choices of strategy in conflict management among Israeli nurse managers in general hospitals, Journal of Nursing Management, 13: Hutchinson, M. & Jackson, D. & Wilkes, L. & Vickers. M.H, A new model of bullying in the nursing workplace, Advances in Nursing Science, 31:E60-E Hutchinson, M. & Vickers, M.H. & Jackson, D. & Wilkes, L., "I'm gonna do what I wanna do. "Organisational change as a legitimized vehicle for bullies, Health Care Management Review, 30: Hutchinson, M. & Vickers, M.H. & Jackson, D. & Wilkes, L., 'They stand you in a corner, you are not to speak: nurses tell of abusive indoctrination in work teams dominated by bullies, Contemporary Nurse, 21: Jackson, D.,& Firtko, A. et al., Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review., Journal of Advanced Nursing, 60: Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 641

28 50 Johnson, S.L., International perspectives on workplace bullying among nurses: a review, International ursing Review, 56: Judkins, S.& Reid, B. et al., Hardiness training among nurse managers: building a healthy workplace., Journal of continuing education in nursing, 37: Kelloway, E.K. & Day, A. L, Building healthy workplaces: What we know so far, Canadian Journal of Behavioural Science, 37: Leiper, J., Nurse against nurse: how to stop horizontal violence, Nursing, 35: Lewis, M.A., Nurse bullying: organizational considerations in the maintenance and perpetration of health care bullying cultures, Journal of Nursing Management, 14: Lewis, T., What must we do about lateral violence?, New Mexico Nurse, 53: Liefooghe, A. P.D. & Olafsson, R., "Scientists" and "amateurs": mapping the bullying domain, International Journal of Manpower, 20: Lim, S. & Cortina, L. M & Magley, V.J., Personal and workgroup incivility: Impact on work and health outcomes, Journal of Applied Psychology, 93: Martin, W. F., Is your hospital safe? Disruptive behaviour and workplace bullying, Hospital Topics, 86: McGillis Hall, L. & Doran, D. & Pink, L., Outcomes of Interventions to improve hospital nursing work environments, JONA, 38: McLemore, M., Workplace aggression: beginning a dialogue, Clinical Journal of Oncology Nursing, 10: Olsen, B. J., D. L. Neslon, et al., Managing aggression in organizations: what leaders must know., Leadership and Organization Development Journal, 27: Pearson, C. M. and C. L. Porath, On the nature, consequences and remedies of workplace incivility: No time for, The Academy of Management Executive, 19: Pearson, C. M., & Andersson, L.M. et al., Assessing and attacking workplace incivility., Organizational Dynamics, 29: Poilpot-Rocaboy, G. & Winter, R., Combating psychological harassment in the workplace: processes for management interventions, International Employment Relations Review, 13: Porto, G. and R. Lauve, Disruptive clinician behaviour: A persistent threat to patient safety., Patient Safety and Quality Healthcare., 29: Quine, L., Workplace bullying in nurses, Journal of Health Psychology, 6: Ramos, M.C., Eliminate destructive behaviours through example and evidence, Nursing Management, 37: Randle, J. & Stevenson, K. et al, Reducing workplace bullying in healthcare organisations, Nursing Standard, 21: Rayner, C., From research to implementation: finding leverage for prevention., International Journal of Manpower, 20: Rocker, C.F., Addressing nurse-to-nurse bullying to promote nurse retention, Online Journal of Issues in Nursing, 13: Rosenstein, Alan H., Nurse-Physician relationships: Impact on nurse satisfaction and retention, AJN, 102: Rutherford, A, & Rissel, C., A survey of workplace bullying in a health sector organisation, Australian Health Review, 28: Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 642

29 73 Salin, D., Organisational responses to workplace harassment., Personnel Review, 38: Sheehan, Michael, Workplace bullying: responding with some emotional intelligence, International Journal of Manpower, 20: Sheehan, Michael & Barker, M. & Rayner, C., Applying strategies for dealing with workplace bullying, International Journal of Manpower, 20: Shuttleworth, A., Managing workplace stress: how training can help, Industrial and Commercial Training, 36: Simpson, K. R., Disruptive Clinician Behaviour., MCN: The American Journal of Maternal Child Nursing, 32: Sotile, W.M. & Sotile, M. O., How to shape positive relationships in medical practices and hospitals, Physician Executive, 25: Stevens, S., From the field. Nursing workforce retention: challenging a bullying culture: how nurses in one Australian hospital confronted intimidation of and by nurses and took steps to remedy it., Health Affairs, 21: Taylor, B., Identifying and transforming dysfunctional nurse-nurse relationships through reflective practice and action research., International journal of nursing practice, 7: Thomas, S. P., Anger: The mismanaged emotion, MEDSURG Nursing, 12: Townend, A, Understanding and addressing bullying in the workplace, Industrial and Commercial Training, 40: Van Fleet, D.D. & Griffin, R.W., Dysfunctional organization culture: The role of leadership in motivating dysfunctional work behaviours, Journal of Managerial Psychology, 21: Weiss, Barbara, Balancing act. Making it work with difficult people, RN, 68: Williams, R., Capturing the moment, Nursing Management, 14: Woelfle, C.Y. & McCaffrey, R., Nurse on Nurse, Nursing Forum, 42: Zwarenstein, M. B. W., Interventions to promote collaboration between nurses and doctors, Cochrane Database Systematic Reviews, : Appendix IV: Critical Appraisal instruments QARI Appraisal instrument Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 643

30 NOTARI Appraisal instrument MAStARI Appraisal instrument Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 644

31 Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 645

32 Appendix V: Data extraction tools Qari data extraction instrument Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 646

33 MAStARI data extraction instrument Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 647

34 NOTARI data extraction instrument Rogers-Clark et al Disruptive behaviour in nursing work place the authors 2009 page 648

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