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Bullying, discrimination, and sexual harassment among intensive care unit nurses in Australia and New Zealand: An online survey

Published:October 06, 2022DOI:https://doi.org/10.1016/j.aucc.2022.08.010

      Abstract

      Background

      Bullying, discrimination, and sexual harassment are significant problems within healthcare organisations but are often under-reported. Consequences of these behaviours within a healthcare setting are wide ranging, affecting workplace environments, personal well-being, and patient care and leading to increased staff turnover and quality of patient care and outcomes. Whilst there has been some work undertaken in the general nursing workforce, there is a dearth of evidence regarding the extent and impact of these behaviours on the nursing workforce in intensive care units (ICUs) in Australia and New Zealand.

      Objective

      We aimed to determine self-reported occurrences of bullying, discrimination, and sexual harassment amongst ICU nurses in Australia and New Zealand.

      Methods

      A prospective, cross-sectional, online survey of ICU nurses in Australia and New Zealand was undertaken in May–June 2021, distributed through formal colleges, societies, and social media. Questions included demographics and three separate sections addressing bullying, sexual harassment, and discrimination.

      Results

      In 679 survey responses, the overall reported occurrences of bullying, discrimination, and sexual harassment in the last 12 months were 57.1%, 32.6%, and 1.9%, respectively. Perpetrators of bullying were predominantly nurses (59.6%, with 57.9% being ICU nurses); perpetrators of discrimination were nurses (51.7%, with 49.3% being ICU nurses); and perpetrators of sexual harassment were patients (34.6%). Respondents most commonly (66%) did not report these behaviours as they did not feel confident that the issue would be resolved or addressed.

      Conclusions

      Determining the true extent of bullying, discrimination, and sexual harassment behaviours within the ICU nursing community in Australia and New Zealand is difficult; however, it is clear a problem exists. These behaviours require recognition, reporting, and an effective resolution, rather than normalisation within healthcare professions and workplace settings in order to support and retain ICU nursing staff.

      Keywords

      1. Introduction

      Bullying, discrimination, and sexual harassment are significant problems within healthcare organisations but are often under-reported.
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      Consultants as victims of bullying and undermining: a survey of royal college of obstetricians and gynaecologists consultant experiences.
      Barriers to and concerns regarding reporting bullying are frequently cited.
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      • Gray C.
      • et al.
      Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence, impact and barriers to reporting.
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      ‘It feels like being trapped in an abusive relationship’: bullying prevalence and consequences in the New Zealand senior medical workforce: a cross-sectional study.
      Nurses are the largest professional group within the intensive care unit (ICU) workplace, with approximately 10,011 full-time equivalent nurses working in a mix of public, private, rural, regional, and metropolitan ICUs in Australia and New Zealand.
      ANZICS Centre for Outcome and Resource Evaluation (CORE)
      ANZICS centre for outcome and resource evaluation 2018 report.
      In 2019–2020, 2596 adult and paediatric beds in 223 ICUs in Australia and New Zealand admitted approximately 216,969 patients.
      ANZICS Centre for Outcome and Resource Evaluation (CORE)
      Australia and New Zealand intensive care resources and activity report 2019/20.
      Bullying is the ongoing and deliberate misuse of power through repeated verbal, physical, and/or social behaviour that intends to cause physical, social, and/or psychological harm.
      Alannah and Madeline Foundation
      National Centre Against Bullying.
      Bullying may create a risk to health and safety and may be direct or indirect
      College of intensive care medicine of Australia and New Zealand
      Prevention of bullying, discrimination and harassment in the workplace.
      ,
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      Our own worst enemies: the nurse bullying epidemic.
      (See Supplemental appendix for full definitions).
      Discrimination is the unjust or prejudicial treatment of different categories of people, especially on the grounds of race, age, sex, disability, religion, marital status, employment status, political opinion, or being affected by domestic violence.

      Oxford University Press. Lexico.com: Lexico.com; 2020 [cited 2020 15 October].

      Employment Relations Act, (19 August 2000, 2000). Available from: http://www.legislation.govt.nz/act/public/2000/0024/112.0/DLM58317.html.

      Fair Work Act 2009, [cited 18 November 2020]. Available from: javascript:openWebLink: https://www.legislation.gov.au/Details/C2010C00741.

      Discrimination also occurs within groups
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      The experience of discrimination by US and internationally educated nurses in hospital practice in the USA: a qualitative study.
      and can cause feelings of vulnerability, powerlessness, intimidation, and humiliation.
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      Discrimination, work and health in immigrant populations in Spain.
      Sexual harassment is any unwelcome or offensive sexual behaviour that is repeated or is serious enough to have a harmful effect or which contains an implied or overt promise or preferential treatment or an implied or overt threat of detrimental treatment.
      The Human Rights Commission
      Sexual harassment: what you need to know.
      Consequences of these behaviours are wide ranging but include cynicism, loss of empathy, and burnout, affecting personal well-being, workplace environments, staff retention, and patient care.
      • Shabazz T.
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      • Oates S.
      • Henderson S.
      • Mountfield J.
      Consultants as victims of bullying and undermining: a survey of royal college of obstetricians and gynaecologists consultant experiences.
      ,
      • Chambers C.N.L.
      • Frampton C.M.A.
      • McKee M.
      • Barclay M.
      ‘It feels like being trapped in an abusive relationship’: bullying prevalence and consequences in the New Zealand senior medical workforce: a cross-sectional study.
      ,
      • Guo L.
      • Ryan B.
      • Leditschke I.A.
      • Haines K.J.
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      • Eriksson L.
      • et al.
      Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review.
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      High level of burnout in intensivists: prevalence and associated factors.
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      Serious implications exist for self-esteem,
      • Randle J.
      Bullying in the nursing profession.
      mental health, and physical health. Depression, helplessness, anxiety, despair, suicidal ideation, psychosomatic complaints, and an increased risk of cardiovascular disease may result.
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      • Morrow G.
      • Burford B.
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      • et al.
      Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence, impact and barriers to reporting.
      ,
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      Systematic review of the prevalence, impact and mitigating strategies for bullying, undermining behaiour and harassment in the surgical workplace.
      Fostering unacceptable behaviours may lead to reduced performance, situational awareness, communication of safety issues, teaching and learning effectiveness, and increased adverse outcomes and patient complaints.
      • College of Intensive Care Medicine of Australia and New Zealand Welfare Special Interest Group
      Culture and health care organisations – so what if we have a problem?.
      In New Zealand, employees are protected from sexual and racial harassment in the workplace under the Employment Relations Act 2000

      Employment Relations Act, (19 August 2000, 2000). Available from: http://www.legislation.govt.nz/act/public/2000/0024/112.0/DLM58317.html.

      and the Human Rights Act 1993.
      In Australia, under the Fair Work Act (2009), workers have the right to be free from bullying and discrimination in the workplace.

      Fair Work Act 2009, [cited 18 November 2020]. Available from: javascript:openWebLink: https://www.legislation.gov.au/Details/C2010C00741.

      The Sex Discrimination Act 1984 prohibits discrimination on the basis of sex, sexual orientation, marital or relationship status, gender identity, intersex status pregnancy, or breastfeeding and promotes gender equality.

      Australia: Act No. 4 of 1984, Sex Discrimination Act 1984, Stat. C2014C00002 [cited 18 November 2020]. Available from: https://www.legislation.gov.au/Details/C2014C00002.

      , The United Nations Declaration on the Rights of Indigenous Peoples provides a framework of minimum standards for the survival,
      Assembly. UG
      United Nations declaration on the rights of Indigenous peoples: resolution/adopted by the general assembly.
      dignity, and well-being of the Indigenous peoples of the world, while in New Zealand, Te Tiriti o Waitangi (The Treaty of Waitangi) protects the rights of tangata whenua (people of the land), including in the workplace, irrespective of whether bullying occurs as a projection of racism or whether it be bullying to Indigenous peoples per se. In Australia, Indigenous people may be particularly vulnerable but do not have a Treaty to protect their rights.
      While work has been undertaken in the general nursing workforce,
      • Chang H.E.
      • Cho S.-H.
      Workplace violence and job outcomes of newly licensed nurses.
      ,
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      there is a dearth of evidence regarding the extent and impact of these behaviours on nurses in the ICU in Australia and New Zealand. A survey of medical trainees and fellows of the College of Intensive Care Medicine (CICM) of Australia and New Zealand reported the prevalence of bullying, discrimination, and sexual harassment in the ICU as 32%, 12%, and 3%, respectively.
      • Venkatesh B.
      • Corke C.
      • Raper R.
      • Pinder M.
      • Stephens D.
      • Joynt G.
      • et al.
      Prevalence of bullying, discrimination and sexual harassment among trainees and Fellows of the College of Intensive Care Medicine of Australia and New Zealand.
      There are subtle differences between the nursing and medical workforces such as gender makeup, ethnic group, and significant issues such as perception of balance of power that may result in different findings between occupational groups.
      We wanted to know the experience of bullying, discrimination, and sexual harassment amongst ICU nurses in Australia and New Zealand; identify demographic features associated with these behaviours; and determine to what extent these behaviours are reported and to what extent respondents felt that these issues were resolved.

      2. Design

      A prospective, cross-sectional, online survey of ICU nurses in Australia and New Zealand. The investigators overseeing this study included ICU clinicians, researchers, and academics experienced in quantitative and qualitative research methodologies and included Māori and Indigenous Australian researchers who were instrumental in analysing and understanding the data from a cultural perspective.

      2.1 Ethical approval and informed consent process

      The study was approved in New Zealand by the Auckland Human Research Ethics Committee (#22006) and in Australia by the Human Research Ethics Committee, University of Southern Queensland (#H21REA061).
      Information regarding purpose, design, and requirements of the study; data storage, security, and anonymity; contact details for the researcher; ethical approval; and support services was available to prospective participants in a letter of invitation displayed at the beginning of the online questionnaire.
      Participation was voluntary. Potential participants were asked to select a tick box to confirm they had read the information sheet and consented to participate. Access to the survey was denied unless this tick box was selected. Withdrawal from the survey was possible by participants deleting their responses before submitting the online questionnaire or by the end of the survey period if the online questionnaire was closed without being submitted.

      2.2 Development, pretesting, and survey administration

      An online survey was developed using Qualtrics (Qualtrics, Provo, UT, USA). The survey was designed with reference to good practice in the conduct and reporting of survey research
      • Kelley K.
      • Clark B.
      • Brown V.
      • Sitzia J.
      Good practice in the conduct and reporting of survey research.
      divided into three main sections, separately addressing bullying, sexual harassment, and discrimination and based on that used by the CICM.
      • Venkatesh B.
      • Corke C.
      • Raper R.
      • Pinder M.
      • Stephens D.
      • Joynt G.
      • et al.
      Prevalence of bullying, discrimination and sexual harassment among trainees and Fellows of the College of Intensive Care Medicine of Australia and New Zealand.
      Demographic data were collected reporting description of job, gender, ethnicity, age, qualifications, length of time since qualification gained, area of work, and level and type of ICU (see Supplemental appendix for survey). The survey was pilot tested to determine adequacy and ordering of questions, comprehensiveness of the contents including letter of invitation, and if instructions were clear and to assess feasibility of the study platform. Adjustments were made to ordering following feedback.
      Respondents were asked a series of questions to identify whether they had or had not experienced bullying, discrimination, and sexual harassment in their workplace in the preceding 12 months. If they reported they had, they were asked how frequently this had occurred, to give an example of what occurred and where it occurred, who displayed this behaviour, whether they had or had not reported the behaviour, measures taken to remedy the situation, and what the outcome was.
      Participants were also asked to briefly describe the worst example of bullying, discrimination, and sexual harassment they had experienced in the last 12 months, avoiding the use of identifying information.
      The survey was open for a 6-week period, from 3rd May, 2021 to 16th June, 2021. Reminders were sent out via email at the 4-week mark and at 4 and 5 weeks via social media.

      2.3 Recruitment process and description of sample having access to questionnaire

      The target population for this open survey were nurses working in or nurses who had worked in ICUs in Australia and New Zealand in the preceding 12 months. All potential participants were given the same project information and gained access to the survey via the same web link. The survey was distributed through email lists administered by the New Zealand College of Critical Care Nurses (NZCCCN), the Australian College of Critical Care Nurse (ACCCN), and the Intensive Care Research Coordinators Group, Australia and New Zealand. Social media platforms Facebook, Twitter, and LinkedIn were used to promote awareness of the survey. Snowball sampling was encouraged.

      2.4 Response rates and estimated sample size

      It was difficult to quantify exact numbers of ICU nurses who would receive this survey; however, there were approximately 10,011 full-time equivalent nurses working in the ICU in Australia and New Zealand.
      ANZICS Centre for Outcome and Resource Evaluation (CORE)
      ANZICS centre for outcome and resource evaluation 2018 report.
      Assuming a 5% margin of error and confidence level of 95%, from a population size of 10,000, a sample size of 370 was required to provide adequate power to answer the research questions.

      2.5 Risk management

      We recognised that participating in this survey might raise issues that caused discomfort or anxiety for respondents. Risk management included directing respondents to community resources as appropriate in each country such as Need to Talk? Samaritans, Lifeline Aotearoa or The Human Rights Commission, New Zealand, Lifeline Australia, Beyond Blue, The Australian Human Rights Commission, Police or Ambulance.

      2.6 Data protection

      No identifying data were collected. All data were anonymous, and no IP addresses were stored or downloaded. Study data were downloaded and entered into a password-protected database. Only the study management committee and statistician had access to raw data.
      Participants were able to erase, skip questions, or backtrack through the survey to review or change their responses. Once the survey was submitted, they were no longer able to withdraw their data.

      3. Data analysis

      Once the survey was closed, data were exported from Qualtrics into Stata (version 17 StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC.) for statistical analysis. Sample characteristics and responses to questions on participant experiences of each of bullying, discrimination and sexual harassment were described using frequencies and percentages. Respondents who reported “no” to having ever experienced bullying, discrimination or sexual harassment but “yes” to having experienced the same behaviour in the last 12 months were recoded to “yes” for having ever experienced that behaviour (n = 2 bullying, n = 8 discrimination, n = 3 sexual harassment). As a sensitivity analysis, the proportion of reports of bullying, discrimination, and sexual harassment were separately summarised for participants who did not report their personal characteristics. Fisher's exact test was used to compare the proportion reporting these behaviours ever and within the last 12 months according to nurses' gender, ethnicity, age group, and country of residence, with those not reporting their personal characteristics being included as a separate group for each variable. A p < 0.05 was considered statistically significant.
      Qualitative data were analysed using NVivo to support content analysis. Free-text responses were extracted from the online survey and read and analysed by three researchers (MC, KM, and RP). Reading and rereading the responses was used to form codes and to then classify content into themes. Seven themes were identified regarding bullying, 13 regarding discrimination, and three regarding sexual harassment. Themes were then discussed and refined by all members of the research team.
      Questionnaires terminated early were recorded after the survey was closed and have been included in the analysis. We removed responses where consent was given but no questions were answered.

      4. Results

      A total of 655 survey responses were received, of which 629 were included in the analysis. Twenty-six responses did not contain any data. Characteristics of respondents are shown in Table 1. Of note, 127 (20.2%) did not answer any of the “characteristics” questions and so have no information on the variables displayed in Table 1.
      Table 1Respondent characteristics.
      CharacteristicN (%)
      Gender
       Female426 (67.7%)
       Male68 (10.8%)
       Nonbinary1 (0.2%)
      Did not answer/prefer not to say134 (21.3%)
      Ethnicity
       Māori20 (3.2%)
       Pacific (Cook Island Māori, Tongan, Other Pacific peoples)3 (0.5%)
       NZ European102 (16.2%)
       Australian250 (39.7%)
       Other European59 (9.4%)
       Aboriginal and/or Torres Strait Islander5 (0.8%)
       Asian (Chinese, Filipino, Korean, SE Asian)32 (5.1%)
       Indian17 (2.7%)
       Other8 (1.3%)
      Did not answer/prefer not to say133 (21.1%)
      Age group
       20–29 years89 (14.1%)
       30–39 years156 (24.8%)
       40–49 years108 (17.2%)
       50–59 years99 (15.7%)
       60+ years37 (5.9%)
      Did not answer140 (22.3%)
      Age, in years
       Mean (SD)41.24 (11.45)
       Min – Max22–74
      Highest qualification
       Diploma18 (2.9%)
       Bachelors degree115 (18.3%)
       Postgraduate certificate/diploma268 (42.6%)
       Masters degree86 (13.7%)
       PhD8 (1.3%)
       Other (please specify)5 (0.8%)
      Did not answer129 (20.5%)
      Country
       Australia326 (51.8%)
       New Zealand170 (27.0%)
      Did not answer133 (21.1%)
      Position
       Designated senior nursing position147 (23.4%)
       Registered nurse328 (52.1%)
       Nurse technician2 (0.3%)
       Enrolled nurse/other3 (0.5%)
       Research position22 (3.5%)
      Did not answer127 (20.2%)
      Employment status
       Full-time251 (39.9%)
       Part-time226 (35.9%)
       Casual12 (2.0%)
       Not currently working in an ICU12 (2.0%)
      Did not answer130 (20.7%)
      Working pattern
       Days or mainly days102 (16.2%)
       Nights or mainly nights39 (6.2%)
       Mixture of days and nights358 (56.9%)
      Did not answer130 (20.7%)
      ICU experience
       <1 year101 (16.1%)
       1–5 years99 (15.7%)
       5–10 years140 (22.3%)
       10+ years137 (21.8%)
      Did not answer152 (24.2%)
      ICU experience, in years
       Mean (SD)13.45 (10.34)
       Min – Max0–44
      Time since registration
       <1 year46 (7.3%)
       1–5 years108 (17.2%)
       5–10 years150 (23.8%)
       10+ years188 (29.9%)
      Did not answer137 (21.8%)
      Time since registration, in years
       Mean (SD)17.65 (11.75)
      Level of ICU
       Level 166 (10.5%)
       Level 291 (14.5%)
       Level 3318 (50.6%)
      Did not answer154 (24.5%)
      Type of ICU
      Multiple responses were allowed, and therefore, the percentages do not sum to 100. Definitions of terms can be found in the Supplemental appendix.
       Rural10 (1.6%)
       Regional53 (8.4%)
       Metropolitan111 (17.6%)
       Public155 (24.6%)
       Private17 (3.9%)
      Did not answer128 (20.3%)
      ICU, intensive care unit; SD, standard deviation.
      a Multiple responses were allowed, and therefore, the percentages do not sum to 100. Definitions of terms can be found in the Supplemental appendix.
      Experiences of bullying, discrimination and sexual harassment during their career were reported by 78.7%, 42.1%, and 31.3% of respondents, respectively, while in the last 12 months, 57.1%, 32.6%, and 12.9% reported these behaviours (Table 2). Of the whole sample, 555 (88.4%) reported “yes” experiencing at least one of bullying, discrimination and/or sexual harassment in their career, while 34 (5.4%) reported “maybe” to ever experiencing at least one of bullying, discrimination and/or sexual harassment in their career. Of the whole sample, 426 (67.7%) reported “yes” to experiencing at least one of bullying, discrimination and/or sexual harassment in the last 12 months.
      Table 2Reports of bullying, discrimination, and sexual harassment amongst 629 ICU nurses in New Zealand and Australia.
      Bullying n (%)Discrimination n (%)Sexual harassment n (%)
      Ever personally experienced BDSH in nursing career
       No83 (13.2%)221 (35.1%)298 (47.4%)
       Maybe49 (7.8%)71 (11.3%)32 (5.1%)
       Yes495 (78.7%)265 (42.1%)197 (31.3%)
      Did not answer2 (0.3%)72 (11.4%)102 (16.2%)
      Experienced BDSH in workplace during the last 12 months
       No264 (42.0%)351 (55.8%)447 (71.1%)
       Yes359 (57.1%)205 (32.6%)81 (12.9%)
      Did not answer6 (1.0%)73 (11.6%)101 (16.1%)
      Frequency experienced BDSH over the last 12 months
      Of those who responded “yes” to having experienced bullying, discrimination, or sexual harassment (as relevant) in the last 12 months, i.e., n = 349 for bullying, n = 205 for discrimination, and n = 81 for sexual harassment.
       One-off event29 (8.1%)32 (15.6%)21 (25.9%)
       2–3 occasions134 (37.3%)85 (41.5%)35 (43.2%)
       More than 3 occasions139 (38.7%)66 (32.2%)20 (24.7%)
      Did not answer57 (15.9%)22 (10.7%)5 (6.2%)
      Chose to report behaviour experienced in the last 12 months
      Of those who responded “yes” to having experienced bullying, discrimination, or sexual harassment (as relevant) in the last 12 months, i.e., n = 349 for bullying, n = 205 for discrimination, and n = 81 for sexual harassment.
       No217 (60.4%)137 (66.8%)54 (66.7%)
       Yes85 (23.7%)46 (22.4%)20 (24.7%)
      Did not answer57 (15.9%)22 (10.7%)7 (8.6%)
      Who displayed behaviour experienced in the last 12 months
      Of those who responded “yes” to having experienced bullying, discrimination, or sexual harassment (as relevant) in the last 12 months, i.e., n = 349 for bullying, n = 205 for discrimination, and n = 81 for sexual harassment.
      ,
      Nurse includes ICU nurse, nurse from another specialty; medical doctor includes consultant from another specialty, fellow/registrar from another specialty, ICU consultant, ICU fellow, ICU registrar; administration includes administrative staff member and ward clerk; other includes healthcare assistant, ICU service clinical director, orderly, patient visitor, other.
       Nurse214 (59.6%)106 (51.7%)19 (23.5%)
       Medical doctor47 (13.1%)26 (12.7%)11 (13.6%)
       Administration1 (0.3%)0 (0.0%)1 (1.2%)
       Patient4 (1.1%)16 (7.8%)28 (34.6%)
       Other27 (7.5%)23 (11.2%)12 (14.8%)
      Did not answer66 (18.4%)34 (16.6%)10 (12.3%)
      BDSH, bullying, discrimination and sexual harassment; ICU, intensive care unit.
      a Of those who responded “yes” to having experienced bullying, discrimination, or sexual harassment (as relevant) in the last 12 months, i.e., n = 349 for bullying, n = 205 for discrimination, and n = 81 for sexual harassment.
      b Nurse includes ICU nurse, nurse from another specialty; medical doctor includes consultant from another specialty, fellow/registrar from another specialty, ICU consultant, ICU fellow, ICU registrar; administration includes administrative staff member and ward clerk; other includes healthcare assistant, ICU service clinical director, orderly, patient visitor, other.
      Of those who reported having experienced these behaviours in the last 12 months, only 23.7%, 22.4%, and 24.7% stated they had reported the bullying, discrimination, or sexual harassment behaviour, respectively (Table 2). Ten respondents had chosen to leave their ICU nursing role due to bullying and eight due to discrimination. All had reported the behaviour.
      The most reported perpetrators of bullying and discrimination behaviours were fellow ICU nurses, while patients were most commonly cited as perpetrating sexual harassment (Table 2, Table 3).
      Table 3Full response options for “who displayed this behaviour”.
      Who displayed this behaviourBullying (N = 359 reports)
      Of those who responded “yes” to having experienced bullying, discrimination, and/or sexual harassment (as relevant) in the last 12 months, including 89 for bullying, 36 for discrimination, and 8 for sexual harassment.
      Discrimination (N = 205 reports)
      Of those who responded “yes” to having experienced bullying, discrimination, and/or sexual harassment (as relevant) in the last 12 months, including 89 for bullying, 36 for discrimination, and 8 for sexual harassment.
      Sexual harassment (N = 81 reports)
      Of those who responded “yes” to having experienced bullying, discrimination, and/or sexual harassment (as relevant) in the last 12 months, including 89 for bullying, 36 for discrimination, and 8 for sexual harassment.
      ICU nurse208 (57.9%)101 (49.3%)18 (22.2%)
      Nurse from another specialty6 (1.7%)5 (2.4%)1 (1.2%)
      ICU consultant32 (8.9%)19 (9.3%)4 (4.9%)
      ICU fellow1 (0.3%)0 (0.0%)1 (1.2%)
      ICU registrar8 (2.2%)4 (2.0%)4 (4.9%)
      Consultant from another specialty5 (1.4%)2 (1.0%)1 (1.2%)
      Fellow/registrar from another specialty1 (0.3%)1 (0.5%)1 (1.2%)
      Ward clerk1 (0.3%)0 (0.0%)1 (1.2%)
      Patient4 (1.1%)16 (7.8%)28 (34.6%)
      Patient visitor2 (0.6%)4 (2.0%)0 (0.0%)
      ICU service clinical director0 (0.0%)1 (0.5%)2 (2.5%)
      Orderly2 (0.6%)0 (0.0%)2 (2.5%)
      Healthcare assistant1 (0.3%)0 (0.0%)1 (1.2%)
      Other (please specify)22 (6.1%)18 (8.8%)7 (8.6%)
      Did not answer66 (18.4%)34 (16.6%)10 (12.3%)
      ICU, intensive care unit.
      a Of those who responded “yes” to having experienced bullying, discrimination, and/or sexual harassment (as relevant) in the last 12 months, including 89 for bullying, 36 for discrimination, and 8 for sexual harassment.
      Behaviours were seen more often in public ICUs, metropolitan ICUs, and level 3 ICUs (Supplemental appendix Table 1). Most commonly there were policies in units or hospitals and mandatory training provided regarding behaviours of concern (Supplemental appendix Table 2).
      Respondents most commonly did not report the experienced behaviours (Table 2). On average, respondents gave three reasons (minimum 1, maximum 7) as to why they did not report an issue, with the most common reason being that they did not feel confident that the issue would be resolved or addressed (Fig. 1). Explanations provided for not reporting included ‘The problem is a systemic problem rather than a single person i.e. involves members of senior nursing team, educators, management and ICU medical staff’ (P04); comments regarding normalisation within unit culture ‘Bullying in this ICU is graded not challenged or dealt with’ (P346)It's the unit culture’ (P412) and ‘Its a known issue that will never change. Plus extremely poor culture within this unit’ (P529); belief that nothing would come of the report ‘Nothing would happen’ (P513) and ‘I felt that it would not be taken seriously’ (P450); and the idea of accepting something as part of the job ‘As the patient was the one with the inappropriate comments I felt I couldn't report it as I am caring for them and usually we accept bad behaviour’ (P144).
      Fig. 1
      Fig. 1Reasons for not reporting bullying, discrimination and sexual harassment, amongst 216, 137 and 54 nurses, respectively, who stated that they did not report an issue they experienced.
      In those who had ever experienced behaviours of concern, associations were seen between ethnicity and bullying; and between gender, ethnicity, country and discrimination, while no significant association was seen between any prespecified groups and sexual harassment.

      4.1 Analysis of nonrespondent data

      We summarised reports of behaviours separately for nurses who did not answer any personal characteristic questions, n = 127 (Supplemental appendix Table 3). Proportions for bullying were similar to the rest of the sample; however, nearly all nurses who did not answer the discrimination or sexual harassment questions were those not reporting their characteristics. A higher proportion of nurses who did not answer the characteristics questions also did not answer the questions around reporting of behaviour. A higher proportion (70.1%, Supplemental appendix Table 3) of nurses who did not complete the personal characteristics questions experienced bullying in the last 12 months, when compared to the rest of the sample (57.1%, Table 2).

      4.2 Analysis of reported behaviours by nurse characteristics

      Significant differences were observed in those ever having experienced bullying and discrimination according to age, gender, ethnicity, and/or country of residence, while respondents in the “did not answer” groups had higher levels of reported discrimination than most other groups (Supplemental appendix Table 4). For respondents who had experienced the behaviours in the last 12 months, significant associations were seen with gender, ethnicity, age group, and country for bullying and discrimination, while ethnicity and age group were associated with sexual harassment. In this group, the average age of nurses reporting sexual harassment within the last 12 months was on average 7 years younger (35.3 years versus 42.2 years, p < 0.001) than those not reporting it, while in those ever experiencing sexual harassment, there was no difference (40.7 years versus 41.5 years, p = 0.449) (Supplemental appendix Tables 4 and 5).

      4.3 Qualitative data analysis

      Respondents also provided free-text descriptions of bullying (267 responses), discrimination (161 responses), and sexual harassment (61 responses) (Fig. 2, Supplemental appendix Table 6).
      Fig. 2
      Fig. 2Key themes identified in reports of bullying, discrimination, and sexual harassment by ICU nurses. ICU, intensive care unit.
      Bullying responses described subthemes including teasing and practical jokes, physical and verbal bullying, belittlement and humiliation, aggression and intimidation, exclusion and isolation, and around work expectations.‘This same nurse has also said to me that I need to “hurry up and get pregnant” so all his problems go away’‘Shouted at. talked over, talked down to, ignored, had back turned on me while I was talking’‘If you sit in favour with the senior staff then you can grow and develop and if you don't then you get stuck’‘Persistent slurs against me and my job and team as well as others that are involved in the research that I do. Also includes swearing and “blanking” when walking down corridor’‘She hovers over everything I do, micromanages my every decision, and always treats me like she thinks I'm completely useless, despite me having almost two decades of experience and a post grad qualification’
      When asked to provide examples of discrimination they had experienced, respondents described subthemes including work allocation, religious and political discrimination, personal and family circumstances, age, experience, development opportunities, physical appearance, pregnancy, maternity leave, gender and sexuality, personality, race, ethnicity, and culture.‘Was told I should never have been hired in ICU as I'm only a new graduate who's useless and doesn't know anything’‘Once you hit 50, your chances of moving up the food chain diminish’‘When I was pregnant I was taken off working in charge shifts because of my ‘condition’’‘Comments from patient and family saying they want an English speaking nurse’‘Other nurses joking about my sexual orientation, comments that make me feel uncomfortable’
      Experiences of sexual harassment centred around themes including physical ‘Being kissed on my head having my hair sniffed’ and verbal harassment ‘I was asked by a registrar whether he could touch my breasts’ and ‘Usually the confused, male patient thinks its ok to inappropriately touch female staff during nursing interventions’, or make sexually explicit comments and electronic messaging ‘Got a text from a ?married doctor saying he would love to show me how much I mean to him’.

      5. Discussion

      We found that ICU nurses in Australia and New Zealand report high levels of bullying (57.1%), discrimination (32.6%), and sexual harassment (12.9%) in the last 12 months. These behaviours were not always reported in the workplace as respondents did not feel confident that the issue would be resolved or addressed. Concerningly, the perpetrators of these behaviours were often fellow nurses. To our knowledge, this is the first report of bullying, discrimination, and sexual harassment experienced by ICU nurses in Australia and New Zealand which resonates with the available literature.
      Hartin et al
      • Hartin P.
      • Birks M.
      • Lindsay D.
      Bullying and the nursing profession in Australia: an integrative review of the literature.
      describe the pervasive nature of bullying in Australia as a matter of significant concern and describe the increasing prevalence and experience of bullying in nursing as a widespread theme in literature. Bullying, discrimination and sexual harassment is common within hospitals, with workplaces being described as ‘a battlefield’.
      • Hartin P.
      • Birks M.
      • Lindsay D.
      Bullying and the nursing profession in Australia: an integrative review of the literature.
      Whilst we could not find any previous reports of bullying, discrimination, and sexual harassment in ICU nurses in Australia and New Zealand, these behaviours have long been recognised in nursing practice,
      • Randle J.
      Bullying in the nursing profession.
      ,
      • Minton C.
      • Birks M.
      • Cant R.
      • Budden L.M.
      New Zealand nursing students' experience of bullying/harassment while on clinical placement: a cross-sectional survey.
      with research suggesting 65–80% of nurses have either experienced or witnessed bullying itself in the workplace.
      • Bloom E.
      Horizontal violence among nurses: experiences, responses and job performance.
      These behaviours negatively impact psychological, physical, emotional, and social areas and effect organisational productivity and patient care and safety. The rates reported in our study are much higher than has been reported in an Australasian survey of ICU medical trainees and fellows (32%, 12%, and 3% respectively).
      • Venkatesh B.
      • Corke C.
      • Raper R.
      • Pinder M.
      • Stephens D.
      • Joynt G.
      • et al.
      Prevalence of bullying, discrimination and sexual harassment among trainees and Fellows of the College of Intensive Care Medicine of Australia and New Zealand.
      Those data are now 6 years old, and in the interim, time and resource has been spent on developing institutional and governmental policies and programmes to raise awareness of these issues and provide mechanisms for redress. This may have contributed to awareness of the issue and encouraged responses in our study. Conversely, it is possible that our data represent an underestimation of these behaviours as possible respondents who had experienced bullying, discrimination or sexual harassment may have not completed the survey as it may have triggered unwelcome memories or were wary of possible identification.
      Of concern is the apparent under-reporting of these behaviours. Our research correlates with previous work which found that of staff who experienced bullying, only 2.7–30.4% reported it
      • Carter M.
      • Thompson N.
      • Crampton P.
      • Morrow G.
      • Burford B.
      • Gray C.
      • et al.
      Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence, impact and barriers to reporting.
      ,
      • Chambers C.N.L.
      • Frampton C.M.A.
      • McKee M.
      • Barclay M.
      ‘It feels like being trapped in an abusive relationship’: bullying prevalence and consequences in the New Zealand senior medical workforce: a cross-sectional study.
      ,
      • Hartin P.
      • Birks M.
      • Lindsay D.
      Bullying and the nursing profession in Australia: an integrative review of the literature.
      and that although policies exist, nurses feel unsupported and rarely enact these policies. Although much has been done recently to highlight these behaviours, it would appear from our study that there is still much to be done to improve reporting mechanisms and outcomes for those who are at the receiving end of these behaviours. Understanding barriers to reporting is important to inform development of policies and guidelines to assist nurses. Our study found that nurses were sceptical about whether issues raised would be resolved and the reasons for nonreporting of behaviours also aligns with previous work. For example, Carter et al. describe that when asked why bullying behaviours were not reported, 14.9% of participants believed nothing would change, 11.3% believed management would not take action, and 10.5% believed the situation might deteriorate further.
      • Carter M.
      • Thompson N.
      • Crampton P.
      • Morrow G.
      • Burford B.
      • Gray C.
      • et al.
      Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence, impact and barriers to reporting.
      Management of bullying must be based on freely reporting bullying behaviours, and staff should not be reluctant to report bullying.
      • Chatziioannidis I.
      • Giuseppina Bascialla F.
      • Chatzivalsama P.
      • Vouzas F.
      • Mitsiakos G.
      Prevalence, causes and mental health impact of workplace bullying in the neonatal intensive care unit environment.
      Our finding that the most common perpetrators of bullying were nurse colleagues, often ICU nurses themselves, is consistent with previous reports that either supervisors or peers in the same work group are the most often cited perpetrators.
      • Carter M.
      • Thompson N.
      • Crampton P.
      • Morrow G.
      • Burford B.
      • Gray C.
      • et al.
      Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence, impact and barriers to reporting.
      ,
      • Chambers C.N.L.
      • Frampton C.M.A.
      • McKee M.
      • Barclay M.
      ‘It feels like being trapped in an abusive relationship’: bullying prevalence and consequences in the New Zealand senior medical workforce: a cross-sectional study.
      ,
      • Chatziioannidis I.
      • Giuseppina Bascialla F.
      • Chatzivalsama P.
      • Vouzas F.
      • Mitsiakos G.
      Prevalence, causes and mental health impact of workplace bullying in the neonatal intensive care unit environment.
      Peer-to-peer bullying has implications for reporting and also for development of interventions and policies aimed at tackling these issues. We may have found high rates of peer-to-peer bullying as nurses are the largest workforce in the ICU.
      These findings should be of importance for those charged with leading ICU nursing workforces as it is possible the high levels reported could impact staff retention. Often what has been described by respondents in this survey is subtle behaviour that makes nurses feel unsafe or unwelcome. Currently organisations are experiencing high levels of staff turnover and critical shortages of nurses, and so issues effecting staff retention and recruitment must be the uppermost for professional organisations and policy development to attract and retain experienced nursing staff. Organisations are not able to lose more staff, experience high rates of absenteeism, or develop retention difficulties and continue to provide effective care.
      Other professional groups such as the Royal Australasian College of Surgeons and the College of Intensive Care Medicine have developed courses such as ‘Operating with Respect’ and ‘Speaking up for Workplace Culture’ to address behaviours of concern. Basic to ‘Speaking up for Workplace Culture’ is the ability to call out inappropriate behaviour at the time it occurs. It must be recognised that the ability to speak up is not easy for many and may be related to culture of the workplace or the employee themselves. Solutions need to highlight the pervasive nature of these issues, promote respect amongst colleagues, and develop support mechanisms to address complaints.
      The results reported in this study should be used to contribute to finding sustainable solutions to these issues to keep well-trained staff in the workplace, flourishing and providing exceptional patient care. The findings of this study will be of significance to all nurses working in the ICU, their managers, clinical directors, and key stakeholders as well as current and future ICU nurses around New Zealand and Australia. These findings can underpin the development of policies and guidelines to support ICU nurses in responding to complaints of bullying, discrimination and sexual harassment in the workplace. They can also be used to guide the development of a Welfare Special Interest Group within the NZCCCN and the ACCCN.
      The first step has been identification of the problem through this binational survey. The second step will be to develop practical and sustainable solutions to issues identified through workplace engagement of key stakeholders and development of policies and guidelines to support identification of and address issues of bullying, discrimination, and sexual harassment. Management of these behaviours requires staff to feel comfortable in reporting issues and in having confidence that action will be taken. As nurses, we owe it to each other to call out these behaviours when we see them and to ensure that unacceptable behaviours are not normalised in the profession and workplace. Staff must learn to, and feel comfortable with, speaking up. Jackson recently stated “speaking up should be ‘business as usual’”.
      • Jackson D.
      When niceness becomes toxic, or, how niceness effectively silences nurses and maintains the status quo in nursing.
      Policies must be developed by and for ICU nurses setting forth expectations for appropriate workplace training and behaviour, encouraging reporting of these behaviours through an effective complaints procedure and by providing support for nurses who undertake this. Both the ACCCN and NZCCCN are well placed to lead this but can only be done by policies being seen as effective and resulting in real change to build staff confidence in reporting and minimise barriers to reporting behaviours. Another suggestion would be to develop peer group supervision which has been shown to be a valuable tool in other nursing workforce groups offering the opportunity to share expertise and experiences whilst providing and receiving feedback and professional sustenance and improving personal well-being and confidence in a safe, confidential place.
      • Tulleners T.
      • Taylor M.
      • Campbell C.
      Peer group clinical supervision for community health nurses: perspectives from an interpretive hermeneutic study.
      We would recommend that this survey be repeated to ascertain change in experience over time and after the implementation of policies and programmes designed to address these behaviours. Recent calls suggest building a culture that supports well-being and culture change, beginning in our training institutions, and based on inclusion, equity, and respect to be paramount for sustaining workforce morale.
      • Murthy V.
      Confronting health worker burnout and well-being.
      We need to perhaps add well-being measure, including reports of bullying, discrimination and sexual harassment to key performance indicators and institutional accreditation standards, to truly see some change.

      5.1 Strengths and limitations

      Strengths of this study include the inclusion of a wide range of ICU nurses from all regions of both countries and all levels of ICU, with ranges of experience, ethnicity, and age. This shows that the survey was seen as important by a broad cohort of ICU nurses and that results will be generalisable across the many and varied ICUs in Australia and New Zealand. The survey was anonymous and had high content validity, and importantly, the study was designed and led by a diverse team of clinicians and researchers including ICU nurses. This gave the survey added mana (prestige and status) and credibility and enabled the researchers to connect with the intended respondents and the professional organisations who championed the work. A further strength was the collection of free-text responses which provided detailed description of the experiences of the respondents.
      Our study has some limitations. The cross-sectional, self-reported design of the study can only provide a snapshot of current levels of these behaviours and cannot imply causation. This survey relied on participants to respond and therefore may be at risk of self-selection bias whereby only those who have experienced these behaviours were more likely to respond to the survey invitation than those who have not. It should be acknowledged that this survey was undertaken during the COVID-19 pandemic, and therefore, responses may reflect different experiences during this time.
      It is difficult to know how many ICU nurses in Australia and New Zealand received the invitation to participate. This was a limitation of the distribution method used; however, we were unable to distribute directly to ICUs due to organisational restrictions on access to staff.
      We also cannot guarantee that respondents were nurses working in Australian and New Zealand ICUs. Due to our choice of survey distribution methods, it is plausible, though we like to think unlikely, that respondents may not have been. Participants were asked to confirm in the consent statement that they were “a nurse working in or has in the last 12 months has worked in an ICU in either Australia or New Zealand”.
      Although we lacked a validated survey tool, this survey closely follows the survey used by CICM annually. The lack of validated definitions of bullying, discrimination, and sexual harassment may be a potential limitation; however, we provided clear definitions to guide those accessing the survey.

      6. Conclusion

      Determining the true extent of bullying, discrimination and sexual harassment behaviours within the community of ICU nurses in Australia and New Zealand is difficult; however, it is clear a problem exists. We need to act now to ensure that these behaviours are recognised, reported, and resolved.
      Bullying is RIFE but not acceptable it is OBVIOUS but not seen by the bully, it is WRONG but ignored by many … we can do this better.

      Conflict of interest

      Samantha Bates is the current Chair of the Intensive Care Research Coordinators Interest Group, Australia and New Zealand. Naomi Hammond is an associate Professor and the Chair of the ACCCN Research Advisory Panel. Steve Kirby was the Chair of the New Zealand College of Critical Care Nurses.

      Funding

      This study received funding in the form of an Early Career Research Excellence Award from the University of Auckland (#3721633).

      Credit authorship contribution statement

      Rachael Parke: Conceptualisation; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualisation; Roles/Writing – original draft; Writing – review & editing.
      Samantha Bates: Conceptualisation; Formal analysis; Investigation; Methodology; Visualisation; Roles/Writing – original draft; Writing – review & editing.
      Melissa Carey: Conceptualisation; Formal analysis; Investigation; Methodology; Validation; Visualisation; Roles/Writing – original draft; Writing – review & editing.
      Alana Cavadino; Formal analysis; Methodology; Validation; Visualisation; Roles/Writing – original draft; Writing – review & editing.
      Adele Ferguson; Conceptualisation; Formal analysis; Investigation; Methodology; Validation; Visualisation; Roles/Writing – original draft; Writing – review & editing.
      Naomi Hammond: Conceptualisation; Formal analysis; Investigation; Methodology; Visualisation; Roles/Writing – original draft; Writing – review & editing.
      Fiona Joyce: Conceptualisation; Formal analysis; Investigation; Methodology; Visualisation; Roles/Writing – original draft; Writing – review & editing.
      Steve Kirby: Conceptualisation; Formal analysis; Investigation; Methodology; Visualisation; Roles/Writing – original draft; Writing – review & editing.
      Tess Moeke-Maxwell: Conceptualisation; Formal analysis; Investigation; Methodology; Visualisation; Roles/Writing – original draft; Writing – review & editing.
      Francis Nona: Conceptualisation; Formal analysis; Investigation; Methodology; Visualisation; Roles/Writing – original draft; Writing – review & editing.
      Kat Mason: Conceptualisation; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Validation; Visualisation; Roles/Writing – original draft; Roles/Writing – original draft; Writing – review & editing.

      Acknowledgements

      We would like to sincerely thank the ICU nurses of Australia and New Zealand for participating in this survey. We also thank the Australian College of Critical Care Nurses, the New Zealand College of Critical Care Nurses, the Intensive Care Research Coordinators Interest Group and the New Zealand Nurses Organisation for their support of this study and help with distributing the survey link. We sincerely thank the University of Auckland for their financial support without which this study would not have been possible.

      Appendix ASupplementary data

      The following is/are the Supplementary data to this article:

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