Integrating an intervention program to eliminate and prevent bullying

1. Integrating an intervention program to eliminate and prevent bullying Margaretha Strandmark Professor Karlstad University, Sweden

2. GullBritt Rahm, Lic. psychotherapist PhD Ingrid Rystedt, MD, PhD Gun Nordström, RN, Professor Bodil Wilde-Larsson, RN Professor Margaretha Strandmark, RN, Professor The research group – a collaboration between Public Health Sciences and Nursing

3. Repeated, systematic, negative, hostile and un-ethical actions over time, where one of the participant is in a disadvantage position and can not defend her/himself towards the other or the group. It is not bullying if the persons involved are equally ‘strong’ or if it is a one-off situation. Olweus 1992; Björkqvist et al. 1994; Leyman, 1996 Definition of bullying

4. A collaborative intervention study, step by step

5. The first step The aim was to map bullying within the health and social care systems, and to investigate possible associations between bullying and psycho-social work environment, as well as health.

6. Questionnaires • Nordic Questionnaire for Psychological and Social Factors at work, QPSNordic34+ • Sense of Coherence, SOC13 • Health Index, HI • The Negative Acts Questionnaire, NAQ-22R • General Health Questionnaire, GHQ-12

7. Sample and response rate • The questionnaires were sent out to 2810 employees at wards at five hospitals and to elderly care settings in five municipalities. • 1550 employees answered the questionnaires (55% response rate).

8. NAQ-22R divided in work-related and personal-related items Examples of work-related questions: Withholding of necessary information affecting the work; ordered to work towards unreasonable and impossible goals. Examples of personal-related questions: Repeated offensive remarks about your person, values, or private life; silence or hostility as response to questions or attempts to conversation.

9. Prevalence of bullied employees from NAQ-22R • Between 33-44 points (occupational bullying, developing bullying) 8.5% • > 45 points ( severe bullying) 2.3% • Exposed to at least one negative acts /week 18.5% • Exposed to at least two negative acts/week 6.8%

10. Additional separate questions • Reported being bullied 4.1% • Reported having witnessed bullying 21.9% • Reported having ever been bullied 38.2%

11. Correlations between NAQ-22R (bullying) and QPS-34 (work environment) • Significant correlation between the questionnaire about negative actions and the questionnaire concerning work environment. • The social/organization related questions have the strongest correlation with negative actions.

12. Preliminary results based on a cluster analyses More severely bullied employees have reduced health and lower Sense of Coherence, as compared to employees who are less bullied.

13. The second step The aim was to explore existing strategies and routines to prevent and manage bullying.

14. Method • In-depth interviews with 12 key persons from one hospital and two municipalities (managers at higher level, HR-partner, staff responsible related to work environment, union representatives, occupational health representatives) • Content analysis (Graneheim & Lundman 2004, Elo & Kyngäs 2008)

15. Findings

16. Categories • Avoiding – sweep the problem under the carpet and an un-clearly definition. • Preventive work environment programs – not specifically directed towards bullying, compiled documents an policies are put on the shelves, inadequate time for psychosocial questions • Identifying and managing – bullying exists, group pressure, different cultures, the chief’s and co-workers’ responsibility • The choice of solution – split the group, and/or work through of the occurrences

17. BULLYING AS THE TOP OF AN ICEBERG Acknowledgement • Identification • Choice of solution Hidden • Avoiding • Work • environment program

18. The third step The aim was to, in collaboration with the workplaces, develop and implement an intervention program to prevent and eliminate bullying

19. Research approach and sample • The research approach was participatory and community based. • Based on questionnaire scores workplaces were selected, in collaboration with the managers on upper level, two eldercare wards and one psychiatric ward for elderly, where bullying problem were presented. • Occupational included assistant nurses, nurses, physicians, physiotherapists, occupational therapists, counsellors and nurse’s assistants. • Interested employees voluntarily enrolled themselves in the focus groups upon our presentation of the project.

20. Individual and focus group interviews • In the first focus group. we investigated how bullying was manifested at the workplace. • In the second focus group, we focused on the components in the intervention program which prevented and eliminated bullying. • In the third focus group, we discussed the suggestions concerning the action plan that the researchers presented, based on the previous interviews. • The interviews were analyzed according to Grounded Theory methodology (Charmaz 2006).

21. Preliminary findings Zero-tolerance Zero-tolerance Zero-tolerance Value-system Atmosphere Organization Zero-tolerance Head Group collaboration Co-workers Awareness Conflict solving Zero-tolerance Zero-tolerance Zero-tolerance

22. Zero-tolerance (no bullying) • The actors consist of the head of the wards, co-workers and the remaining organization. • Work with the value-system, to be aware of the bullying, work against an open atmosphere, group collaboration and conflict resolution are requirement to attain zero-tolerance against bullying.

23. The head of the ward has a keyrole as the spider in the web. In this role she/he collaborate with co-workers and the remaining organization. The role of the head of the ward

24. The actors’ roles • The head of the ward has an intermediate positions in which she/he will be a model, listening, emphatic, resolute and call for demands. • The co-workers have a responsibility to behave themselves professionally towards patients, clients and the head of the ward. • The executive level over the head of the ward is a black box, and experiences as unfairness concerning staffing, work loading, and employments.

25. Categories • A humanistic value system which is based on respect, tolerance and empathy. • An open or a concealed atmosphere consist of possibilities to talk freely or to be stick in the walls. • Collaboration within the group and between the groups included help over the limits, creation of mutual routines, building clicks and informal chiefs.

26. Intervention program From the findings of the interviews an intervention was developed. • From the first focus group we gave a half-day lecture at the workplaces about bullying, conflict management, communication and a feeling of shame. • We also discussed in small groups with all employees based on playing-cards containing bullying situations and possible solutions.

28. With-holding of information

29. Bullied of a co-worker

30. Control of the chief

31. Intervention program c) From the separate interviews and the two first focus groups interviews a suggestion for a concrete action plan was compiled. The plan included the value-system, to recognize bullying and call out, treatment which creates confidence and trust, conflict management, the supervisors’ and co-workers’ roles, dynamic group processes, and arenas to keep the discussion alive. d) The action plan has been presented and discussed in the steering groups of the workplaces.

32. Follow-up the action plan at the workplaces • All employees shall sign the action plan. • New co-workers are assigned a mentor. • The head of the ward is responsible for the plan is followed. • The participates of the focus groups are responsible to keep the discussion alive.

33. Conclusion Zero-tolerance against bullying shall be prevailed. The head of the ward, the co-workers and the remaining organization work together against this goal through a humanistic value-system. To be aware of the bullying, to have an open atmosphere and a good collaboration in the groups is important for conflict resolution and prevention.

34. Evaluation of the results and the implementation • The same questionnaire will be sent out to the workplaces which have implemented the intervention, and to a similar comparison group, where no intervention has occurred. • The fourth focus group interviews, we will discussed whether the implementation was succeeded.

35. Thank you for your attention!