The impacts of organizational culture and neoliberal ideology on the continued existence of incivility and bullying in healthcare institutions:A discussion paper

Michael LaGuardia ,Nelly D.Oelke

a School of Nursing,The University of British Columbia,British Columbia,Canada

b Rural Coordination Centre of British Columbia,British Columbia,Canada

Keywords:Austerity Bullying Health personnel Incivility Neoliberalism Organizational culture Resource allocation

ABSTRACT Countless research studies have demonstrated the detrimental effects of incivility and bullying in healthcare.Despite the abundance of proposed solutions to this issue,many healthcare leaders continue to fail in mitigating the existence of such negative behaviors in the workplace.Personality attributes of perpetrators and victims have received attention,but much less research has examined the organizational and neoliberal causations of incivility and bullying in healthcare.Being the largest occupational group in the health sector,nursing professionals have the greatest influence and are crucial in ending these behaviors.This discussion paper outlines the effects of incivility and bullying in healthcare and provides a critical analysis on how organizational culture and neoliberal ideology influence the pervasiveness and persistence of these negative behaviors.The analysis reveals that organizational cultures that misuse power,disregard equality,and facilitate oppression,foster the existence of incivility and bullying in the workplace.Such cultures permit perpetrators to misuse their authority to control resource allocation,ignorance to social inequalities,and the silence of victims.Furthermore,the neoliberal concept of deregulation,austerity,and individualism further these behaviors.The neoliberal reforms have led to underfunding of anti-bullying programs and policies,use of bullying behaviours as management strategies,and victim-blaming for profit maximization.Financial cutbacks have resulted in denial and acceptance of uncivil and bullying behaviours in healthcare institutions,which endangers the rights of healthcare providers to a safe workplace environment.To curtail these negative behaviors,robust anti-bullying policies and programs must be strictly enforced and sustained in practice.Further exploration on the association of organizational culture and neoliberal principles to incivility and bullying in healthcare is greatly warranted.

What is known?

• Incivility and bullying in healthcare continue to persist despite their detrimental effects on healthcare organizations,employees,and patients.

• Organizational culture plays a crucial part in the development or prevention of incivility and bullying.

• The association of neoliberal principles with uncivil and bullying behaviours in healthcare institutions has been insufficiently scrutinized.

What is new?

• The neoliberal agenda of healthcare reform has allowed uncivil and bullying behaviors to persist due to increased productivity demands,resource conflicts,and employee dissatisfaction.

• The concepts of deregulation,austerity,and individualism disregard the importance of employee policies and programs to mitigate incivility and bullying in healthcare institutions.

• The underfunding of healthcare resources has resulted in the denial and acceptance of incivility and bullying in the workplace,particularly in nursing.

1.Introduction

Despite decades of multiple research studies proving its detrimental effects,incivility and bullying remain common in many workplace environments [1-3].Even healthcare institutions that are established on the practice of compassionate care and a strong code of ethics are not spared from this type of workplace violence.Many organizations have policies to address workplace violence;however,research has found these policies are unclear and ineffective in eradicating workplace incivility and bullying among healthcare professionals [4].There are numerous factors that influence the continued existence of bullying in the workplace,particularly in healthcare.This includes organizational cultures that permit bullying behaviours to flourish by accepting and denying their existence and creating norms that promote occupational inequality [5].Furthermore,the healthcare regulations influenced by neoliberalist ideology with a predominant focus on profit disregard the accountability in healthcare institutions and systems to address this issue [6].Nursing is the largest occupational group in healthcare and possesses the greatest influence on the existence of these negative behaviours,which highlights the importance of nursing professionals in eradicating this issue[7].While there are a myriad of forms of incivility and bullying,the outcomes associated with such behaviours are singularly negative [8].The purpose of this discussion paper is to emphasize the importance of stopping incivility and bullying behaviours in the workplace,explore how organizational culture and neoliberalist ideology lead to the continued existence of incivility and bullying in healthcare,and provide recommendations for policy,practice,and research.This paper will only refer to the incivility and bullying behaviours of professionals employed in healthcare institutions,excluding violent behaviours demonstrated by some patients in the workplace.

2.Background

Workplace violence is a major source of stigmatization,discrimination,conflict,and inequality in the workplace that negatively affects the dignity of many employed people worldwide[9].Incivility and bullying are the most prevalent types of violence that occur in the workplace [10].Incivility is defined as low intensity deviant behaviour by the perpetrator with the ambiguous intent to harm the victim and destroy mutual respect in the workplace [11].Uncivil behaviours may involve intimidation,discourtesy,and rudeness.Bullying behaviours are more robust with higher intensity,longer duration,and increased severity than uncivil behaviours [12].Bullying is defined as negative,repetitive,aggressive,and intentional behaviours that may involve personal attacks,belittlement,threats,intimidation,exclusion,isolation,or humiliation [10].A major distinction between incivility and bullying definitions is that uncivil behaviours can be a one-time occurrence,whereas bullying behaviours are repeated and must occur at least weekly for a minimum of six months [13].

The WHO identified incivility and bullying as a silent epidemic which poses a major public health concern and demands immediate intervention[14].It is reported that 50%of employees globally experience workplace incivility and bullying from their superiors,colleagues,and subordinates [15].However,the true incidence of uncivil and bullying behaviours is presumed to be higher due to the unrecognized and unreported cases in the workplace.

According to the Canadian Centre for Occupational Health and Safety,incivility and bullying are occupational health and safety hazards that negatively affect both individuals and institutions[16].It was found that the majority of reported workplace incivility and bullying occurred in healthcare and primarily involved professional nurses and doctors [15].Furthermore,a recent study in developed countries revealed that 45% of healthcare employees have been bullied [17] and 39% of health professionals witnessed bullying behaviours and were at heightened risk for psychological stress[2].For these reasons,hospitals are categorized as one of the most hazardous workplaces [18].

Organizational culture is the collection of beliefs,values,assumptions,and practices that shape the unique social and psychological environment of an organization [19].Research has shown that organizational culture plays a crucial part in the development or prevention of uncivil and bullying behaviors.The presence of incivility and bullying are found in organizations that ignore,allow,and practice these negative behaviours [20].

Neoliberalism is a political ideology that advocates for the market to foster economic growth and innovation [21].The neoliberal agenda supports deregulation,austerity,privatization,capitalism,and individualism [22].Neoliberal policies place limits on government spending,regulation,and public ownership [23].The adoption of free market approaches has resulted in an increase in inequality and underfunding of healthcare resources to ensure safety [6].Neoliberalism places a greater emphasis on quantity of health services rather than quality of patient care and employee satisfaction.A few of the identified issues arising from this political ideology are lack of accountability of organizations,creation of highly stressful workplaces,and social inequalities [22].Although these are identified to be precursors to workplace incivility and bullying,the effects of neoliberalism on these negative behaviours in healthcare continued to be underexplored.

To elaborate on the significance of this issue,this discussion paper begins by outlining the impacts of incivility and bullying in healthcare institutions,employees,and patients.This is followed by an examination of organizational culture and neoliberal causations that lead to these behaviours in healthcare.A conceptual map illustrating these is shown in Fig.1.Lastly,recommendations for policy,practice,and research to mitigate incivility and bullying in healthcare institutions are presented.This discussion is informed by a review of the literature and encourages nursing professionals and leaders to explore the current political climate affecting healthcare and their critical role in resolving this issue.

3.Effects of incivility and bullying in healthcare

Fig.1.Organizational culture and neoliberal ideology on incivility and bullying in healthcare institutions:A conceptual map.

Healthcare is a dynamic,complex,and often stressful environment and is primed for incivility and bullying behaviours to occur.Multiple research studies have repeatedly indicated the detrimental effects of incivility and bullying in the workplace[4,15,24,25].Healthcare organizations are not immune to the negative effects of such behaviours.In fact,incivility and bullying occur more frequently in healthcare than in any other industries[26].This may be in part due to highly stressful environments and physically limited workspaces that are more likely to lead to negative behaviours [12].The deleterious effects of incivility and bullying are widespread and can negatively impact healthcare institutions,its employees,and their patients.

3.1.Impacts on institutions

Uncivil and bullying behaviours can lead to significant impacts and expenses for healthcare institutions.For example,an institution could be impacted by increases in employee attrition.It has been reported that 25%of victims and 20%of witnesses intended to resign due to uncivil and bullying behaviours[13].The attrition rate that results from workplace bullying alone is 20%,furthering the severity of the current healthcare provider shortages [15].Employee absenteeism,stress leave,and injuries as a result of bullying could increase the operational costs of the institution[10].Employee turnover could affect an institution’s financial performance due to separation,replacement,and training costs [25].Customer service disruptions and underperformance of bullied employees could further lessen the productivity performance of the institution [27].Moreover,it was estimated that unresolved bullying incidences may lead to lawsuits and could cost an institution up to US$ 30,000 per case,increasing to US$ 60,000 if the case goes to court [18].Although the increase in public awareness about bullying continues,more than 72% of organizations deny,discount,encourage,rationalize,or defend bullying behaviours in the workplace[28].Many of these institutional impacts are related to employees that are victims of bullying.

3.2.Impacts on employees

Healthcare professionals are more likely to experience workplace incivility and bullying than employees in other sectors because of the demands and pace of the work environment and the emphasis on performance [24].Research shows a common belief that workplace bullying is a part of the job and that healthcare employees accept it as a routine occupational hazard[29].The risk of healthcare employees experiencing violence is estimated to be 16 times greater than other service workers [15].The impacts of bullying on employees’ job satisfaction,emotional health,and social well-being create significant damage.Many victims experience a loss of meaning derived from work,an inability to focus,and a sensation of dread at the very thought of going to work [30].Victims express feelings of exclusion,isolation,intimidation,belittlement,and humiliation [10,16].Bullying damages the victim’s professional identity,resulting in limitations of career opportunities and chances for job promotions [24,31].

Moreover,there are physiological and psychological effects of bullying that are difficult to ignore.Some physiological health effects of bullying include insomnia,gastrointestinal discomfort,musculoskeletal problems,hypertension,chest pain,palpitations,headaches,and worsening of chronic illnesses [10,11,32].The psychological effects of bullying victimization include anxiety,phobias,panic attacks,depression,loss of libido,post-traumatic stress disorder,and suicidal ideation[30,33].The stress caused by workplace bullying has the potential to affect the victim’s home life,including family,child care,and social relationships [2].Victims also suffer from financial issues due to absences or loss of their jobs [34].Healthcare employees have not reported bullying behaviours for various reasons,including,but are not limited to,productivity demands,hierarchy,and cost control [15].As a result,accurate data about workplace incivility and bullying is non-existent.Workplace violence does not exclusively affect the healthcare institution and its healthcare providers,it also indirectly impacts the health of their patients.

3.3.Impacts on patients

Workplace incivility and bullying has been acknowledged as a hindrance to the delivery of high-quality patient care and threatens patient health outcomes.These behaviours traumatize the workforce and grossly impact patient quality and safety.Many bullied healthcare workers reported knowing medical errors,malpractices,and procedural violations that resulted from disruptive or bullying behaviors [35].Patients of bullying physicians had 14% more complications post-operatively than those patients treated by surgeons exhibiting positive behaviours and professional manners[36].It has been revealed that 94% of professional nurses felt that bullying behaviours had negative impacts on patient outcomes while 54% state that patient safety was at risk [1].Patient safety issues may be related to how bullying is perceived,causing a decrease in staff motivation and commitment to their employers,and the ability to concentrate on the job [31].These place the employees at a greater risk of making practice errors.Medical errors are the third leading cause of patient deaths with high incidences directly caused by poor team communications hampered by workplace incivility and bullying [11].

4.Organizational culture

Organizational culture is often cited as a factor contributing to the emergence of incivility and bullying behaviours.Researchers believe that the precursors to continued existence of workplace violence are found in cultures that misuse power,disregard equality,and facilitate oppression [5,18,37].Some authors view bullying in healthcare environments as a direct reflection of power imbalances that originate from the hierarchical structures existing in many institutions [1].Those individuals at the top of the hierarchy possess the power to bully their subordinates,solely by virtue of their position [18].Unfortunately,perpetrators have been associated with traits such as being powerful figures in the workplace with the ability to manipulate distribution of resources,experts in their fields of practice,having strong personalities,and possessing control over organizational functions [4,13,36].

Whether it is exercising power of authority or misusing the hierarchical structure,some physicians,healthcare administrators,nurse managers,and supervisors have been known to bully their colleagues and subordinates[36].The existence of power disparity between the bully and the victim makes it difficult for the victim to bring conflicts to a complete and successful resolution[9].For many employees,income and job security are important;reporting uncivil and bullying behaviours of their superiors may result in wage or job loss[29].Since many perpetrators are in positions of power,there may be a culture of acceptance and denial of such negative behaviors in the workplace.These add to the reasons why many healthcare professionals remain silent and choose not to report bullying behaviors and violent acts perpetrated by their superiors.Many experts believed that all forms of bullying stem from power that is misused and that dysfunctional power dynamics can root itself in an institution and become the cultural norm[4,31,37].This may be one of many reasons healthcare has among the highest incidence of bullying as opposed to other sectors.

Bullying behaviours build on existing embodied,classed,gendered,racialized,and sexualized social inequalities making people accept such inequalities as normal part of daily living[5,12,18,38].There is evidence to suggest that certain individuals or groups are highly vulnerable to occupational inequality and maltreatment due to exploitation,marginalization,and cultural imperialism[38].The minority gender in a workplace is more likely to get bullied,regardless of their sexual orientation [18].Furthermore,marginalized groups such as visible minorities,members of Indigenous groups,and employees in lower social class are considered to be easy targets of bullying behaviours in the workplace [26].The creation of clique groups generate opportunity for the nurturing and hiding of the bully [9].These social inequalities and maltreatment of such groups are highly common not only in healthcare institutions but also in many other sectors and industries [31].Most healthcare professionals have directly experienced or witnessed bullying in some form that may have resulted from occupational or social inequality.

Silencing came from the belief that good nurses do not change the status quo and therefore silence themselves to avoid conflict[39].Some of the origins of bullying in healthcare can be explained using oppression theory.In 1971,it was theorised that oppressed group behaviors can occur when the powerless are submissive and silent in confrontation with authority [5].Consequently,fear and low self-esteem result and lead to internalized anger and aggressive behaviours toward one’s own group members [39].Historically,nurses in hospital settings were argued to be an oppressed group,as these settings were influenced by medical hierarchies and patriarchal structures in which nurses lacked power and control,thus highlighting the vulnerability of nurses and other healthcare employees to workplace aggression[35].The culture of oppression in nursing is continuing to prevail in many parts of the world,particularly in developing countries [5].

The experience of oppression may result in violence as a way to achieve power over peers[38].However,incivility and bullying also occurs within and among other professions and they can occur top down,bottom up,and horizontally within any team or organization[35].Although nurses and physicians are often considered to be the primary culprit of bullying,healthcare bullies can be any professional who works in a healthcare institution including technologists,pharmacists,allied health care workers,ancillary personnel,administrators,or other non-physician staff members [1,32,37].

5.Neoliberal ideology

Neoliberalism is generally associated with policies aimed at achieving economic stabilization through governmental deregulation,privatization,decentralization,and individualism [21].The neoliberal agenda of healthcare reform includes cost-cutting for efficiency [23].Many developed countries,such as Canada,United Kingdom,and the United States have adopted austerity measures to reduce healthcare expenditures[22].Government deregulation has undermined healthcare through financial cutbacks and new approaches to healthcare management[23].Hospital leadership have adopted management strategies to make hospitals more efficient by reducing the number of nurses and staff or by increasing the number of their patients to provide care at the lowest unit cost[23,40].This approach has led to inadequate skill ratio of staff to effectively deliver healthcare services or monitor patients resulting in healthcare employees’excessive workloads,de-skilling,burnout,and attrition.As a consequence,incivility and bullying among health professionals have remained and progressed due to increased productivity demands and resource conflicts within the workplace [35].

Furthermore,cost-cutting measures have resulted in limited employee resources and support programs for victims of bullying,which may have resulted in the acceptance of uncivil and bullying behaviors as institutional norms.Employee education programs and anti-bullying campaigns are less of a priority for many of these institutions as they make no significant profit through these programs.Many hospitals are hesitant to terminate any staff that would result in difficult to fill vacant positions [10].Replacing employees with specialized skills,such as nurses and physicians,is daunting,time-consuming,and costly [10,16].It is estimated that workplace bullying costs an organization roughly 10% of their profits,forcing organizations to deny and ignore its existence [10].Capitalism and austerity have precipitated underfunding of healthcare resources that have resulted in a myriad of safety issues among healthcare employees and patients [6].Moreover,deregulation has resulted in healthcare institutions’ lack of incitement to take responsibility for the damages they caused [6,21].

Neoliberal principles have promoted organizational culture misuse of power by allowing frontline leaders to deliberately engage in bullying as a management style to increase compliance and minimize complaints of employees [40].Nursing administrators and managers that highly value economic gains have a tendency towards uncivil and bullying behaviours [41].Such a management style creates workplace environments where paternalism,fear,and intimidation are pervasive.This type of work environment challenges the ability of employees to maintain their professionalism;therefore,some participate or submit to such negative behaviours.In some hospitals,legitimate concerns and warnings raised by professional nurses are not always treated equally as those raised by physicians[6].The existence of authority gradients and power imbalance between healthcare professions help condone workplace inequality,incivility,and bullying.

Neoliberal individualism refers to “the belief that the focus of attention with regard to healthcare and health policy should be on the individual rather than on environments and societal institutions or structures” [23,p.15].This principle disregards the environmental and organizational factors that result in uncivil and bullying behaviours,leading to employees being blamed.This gives priority to individual responsibility and choice over concepts of public good.Workplace incivility and bullying and the lack of policy and programs to address them appear deceptively insignificant in this political ideology.Nursing employees and leaders must recognize that their professional responsibilities to ensure a safe work environment are far more important than financial or managerial agendas.

Incivility and bullying resulting from organizational culture and neoliberal ideology are undeniably present in many healthcare institutions.The conceptual map presented in Fig.1 outlines how organizational cultures that misuse power,ignore social inequalities,and facilitate oppression permit uncivil and bullying behaviours to occur.Moreover,it illustrates how neoliberal concepts of deregulation,austerity,and individualism may have allowed these negative behaviours to continue and greatly affect healthcare institutions,professionals,and patients.

6.Recommendations

6.1.Policy

Non-violent forms of workplace aggression such as incivility and bullying are not illegal;therefore,it is critical that healthcare institutions develop robust anti-bullying policies to prevent these behaviors.Although accreditation and regulatory bodies recognize the widespread danger and have implemented practice standards and guidelines to curtail bullying behaviours,organizations have been quite slow to adapt [27].The development of anti-bullying policies to reduce the chance of violence and to build a positive workplace culture would be beneficial if they are strongly enforced[12,35].Healthcare institutions should distinctly state their stance about zero tolerance for incivility and bullying and provide antibullying policies that include clear definitions,explanations,reporting methods,consequences for violations,and antiretaliation provisions [10,35].

To build a policy that will help create an anti-bullying culture,it is crucial to involve actions that will help address the issue when it arises.Such policy should at least include the following:(a) conducting a thorough investigation when bullying is reported,(b)encouraging immediate reporting,(c)ensuring retaliation does not occur,(d)providing training for managers on handling uncivil and bullying behaviours,and (e) enforcing the policy [32].

6.2.Practice

Changing the overall culture at the organizational level is essential to prevent and end workplace incivility and bullying[13,31].Nurses and physicians can set the stage for addressing workplace incivility and bullying by examining and addressing their own behaviours and modifying practices that might be construed as such behaviours [40].It is essential to foster an environment that encourages open communication and collaboration[13].Moreover,healthcare leaders should hold all employees accountable for their behaviour and follow the code of conduct consistently and fairly for all employees,regardless of their professional discipline,position,or seniority [4].

To eradicate uncivil and bullying behaviours in the workplace,it is crucial to establish a system of high institutional responsiveness to bullying.This can be done by assembling an interprofessional committee to address unprofessional behaviours [1].The committee should collaboratively work to develop interpersonal relationship skills and education to effectively address unprofessional and violent behaviors [32].Additionally,nurse leaders need to be educated and trained to recognize and address bullying behaviours within their respective practice areas[2].

Healthcare institutions must develop and implement reporting processes to formally document workplace incivility and bullying incidences.Reporting procedures must be clearly defined,quick,and simple.It is essential that employees are informed about available reporting options,as employees who understand the reporting methodologies are likely to report and document the incidents [39].Victims of bullying must be reassured that their reports will be investigated and kept confidential upon submission.All this in turn,would allow incivility and bullying to be recognized and addressed in a timely manner.Furthermore,organizations need to determine why incivility and bullying is not reported and encourage the reporting of such negative behaviours.Departmental leaders should document all attempts made and actions taken to address bullying and other unprofessional behaviours [29].

6.3.Research

Bullying goes by many names,such as workplace aggression,indirection aggression,relational aggression,workplace violence,vertical violence,horizontal violence,and incivility [12,15,25].In the literature,many of these terms are used interchangeably and researchers have continued to proliferate constructs that label uncivil and bullying behaviors in the workplace,which adds to the challenges of building relevant literature.It is crucial that researchers and educators develop an agreement on a universal concept and definition,rather than contesting the concept of incivility and bullying [30].Furthermore,researchers should focus on redefining the current technical definition of bullying.Bullying behaviours do not need to be occurring at least once a week for six months to be considered as bullying,as the detrimental effects of a single bullying incident could have devastating and lasting effects on victims.It is important to develop a standardized,valid,and reliable measurement tool to quantify and document incivility and bullying in the workplace.

The majority of the literature reviewed focuses on how perpetrators should be punished or disciplined;it is obvious that more research is needed on how to constructively and effectively confront and support the perpetrators in ending their negative behaviours.Moreover,various interventions and violence rehabilitation programs need to be assessed for their effectiveness.Assessment of such programs should include costs and safety benefits to promote sustainability.

The neoliberalization of healthcare has spurred normality in the form of institutional policies,management styles,and workplace culture where uncivil and bullying behaviours become part of daily operations.To help identify and address the destructive consequences of neoliberalism,it is important that neoliberal concepts and principles be explored within this context.Additionally,stress has been associated with these negative behaviours and recent data has proven that frontline nurses experience a high degree of stress during the COVID-19 pandemic,which negatively affects both their physical and mental health[33].An exploration on how the current COVID-19 pandemic and the resulting increase in stress,productivity demands,performance pressures,and resource conflicts may affect uncivil and bullying behaviors is warranted.Since nursing professionals account for approximately 59% of global healthcare workforce,they have the potential to create a significant impact in resolving this issue[7].A lasting change in healthcare will only be achieved when incivility and bullying are addressed collaboratively by all disciplines and by the workforce as a whole.

7.Conclusion

Workplace incivility and bullying within the healthcare system are undoubtedly detrimental to the health of organizations,employees,and patients.It is critical that all health professionals,including nurses,participate in the resolution of this issue by ensuring a respectful workplace and collegial practice.Nurse leaders and managers are in a prime position to address this prevalent issue by developing effective policies,promoting safe workplace culture,and utilizing positive leadership skills.It is the responsibility of all healthcare professionals to build and maintain a healthy workplace environment that allows the provision of ethical,effective,and evidence-informed care.More importantly,nurses must have the courage to challenge the prevailing ideologies and understand what they mean to their organizations,profession,and patients.

Ethical approval

This discussion paper does not contain any studies with human participants or animals performed by any of the authors.

Funding

This work received no public or private funding.

CRediT authorship contribution statement

Michael LaGuardia:Conceptualization,Methodology,Formal analysis,Investigation,Writing-original draft,Writing-review&editing,Visualization.Nelly D.Oelke:Conceptualization,Visualization,Writing-review&editing,Supervision.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A.Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2021.06.002.