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Newly graduated nurses' educational readiness for workplace violence Camacho, Sarah 2017-12-21

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  NEWLY GRADUATED NURSES’ EDUCATIONAL READINESS FOR WORKPLACE VIOLENCE  by SARAH CAMACHO BSN, Ryerson University, 2003  A SCHOLARLY PRACTICE ADVANCEMENT RESEARCH (SPAR) PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF SCIENCE IN NURSING   in the Faculty of Graduate and Postdoctoral Studies (Nursing)   THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) December 2017  © Sarah A. Camacho, 2017  1 ACKNOWLEDGEMENTS   I am extremely grateful for my supervisor Dr. Colleen Varcoe, PhD. Her continuous support, encouragement and guidance throughout this project has been key to my success. Thank you for being my supervisor.  I am also very appreciative of Dr. Victoria Bungay, PhD, who was my second committee member for this SPAR paper.  Your perspectives and recommendations helped me significantly refine this work.  Thank you for your time and contributions to my project. Last but not least a very special thanks to my dear family, my words cannot express how grateful I am to my husband, Robert for his unwavering support throughout my MSN journey. A special appreciation to my daughters, Lily and Eleanore for their constant love.   2 ABSTRACT Workplace violence (WPV) has been a persistent problem in nursing workplaces, one that has serious consequences for new graduate nurses (NG). WPV, in its various forms, diminishes the quality of all nurses’ work lives, and creates recruitment and retention problems for health care organizations. The readiness of NGs to deal with this problem is an important consideration for nursing educators and leaders.  Over the past two decades, substantial attention from nurses, nursing professional organizations, and organizational leaders has focused on the challenges of WPV.  Most of that attention has addressed the interpersonal relationships that are assumed to be the source of the problem, and most nursing education and leadership literature has addressed the problem from this perspective. Far less attention has been directed toward the role of organizational dynamics and their contribution to workplace violence. This scholarly practice advancement research project (SPAR) is an integrative review of current literature addressing NGs readiness for WPV, with a focus on literature addressing the issue of WPV from an organizational perspective.  The primary aim guiding this review was to examine the readiness NGs experience for actual and potential workplace violence.  The review also sought to explore and analyze literature addressing the contextual and relational aspects contributing to workplace violence.    Despite the limited research available on this topic, this review illuminates key organizational dynamics about the context where WPV takes place and highlights what is known about the readiness of NG’s for actual and potential WPV. Eight articles were selected and reviewed, as guided by the main research questions.  The findings of this review revealed that NGs did not perceive themselves to be ready to manage the power dynamics occurring in the workplace.  NGs voiced that lack of support and respect and mistreatment from colleagues came as surprises upon entry into the profession.  This gap between nurses’ preparation and their 3 experience was found to have consequences for NGs in terms of their confidence and overall capacity to learn and practice optimally, for the organization and efforts to retain good nurses, and ultimately, for patients’ and the quality of nursing care.   The literature explored in this SPAR integrative review also identified organizational factors that precipitate and perpetuate WPV, such as workplace environment, misuse of organizational procedures and processes and informal subgroup alliances who help maintain the status quo.  The literature also exposed how surveillance and indoctrination have their roots in institutional power relations and have vital consequences for nursing work and potentially, for the health and safety of patients.  Recommendations focus on proposing changes to nursing education curriculum, educating nurses about power in organizations and assisting NGs to develop skills that help them in shifting organizational cultures.  This SPAR integrative review recommends that leaders in health care organizations make WPV behaviours more visible and be at the forefront of shifting the power dynamics within organizations so no forms of WPV are accepted.   Keywords: workplace violence, nursing graduates, power dynamics, nurse education, organizational dynamics, surveillance, indoctrination, informal subgroup alliances, workplace environment        4 TABLE OF CONTENTS Acknowledgements ....................................................................................................................... 1 Abstract .......................................................................................................................................... 2 List of Tables ................................................................................................................................. 5 Chapter 1: Background and Research Question ....................................................................... 6 Introduction and Background.................................................................................................. 6 Significance and Research Questions .................................................................................... 7 Methodology .........................................................................................................................10 Search Strategies ..................................................................................................................11 Foucault’s Concept of Power.................................................................................................17 Summary...............................................................................................................................19 Chapter 2 Analysis of Findings from the Literature Review .................................................. 20 Introduction ...........................................................................................................................20 Theme 1: NGs were Unprepared for WPV, Mistreatment Came as a Surprise ......................20 Lack of Support and Respect ............................................................................................22 Nursing ‘Cliques’ and Power Games .................................................................................24 Mistreatment by Colleagues ..............................................................................................27 Analysis of the Theme .......................................................................................................28 Summary ...........................................................................................................................30 Theme 2: Health Care Organizations have Institutionalized WPV .........................................30 Organizational Structures Generate Work Environments that Promote WPV ....................31 Organizations use Normalization and Surveillance to Sustain WPV ..................................38 Summary...............................................................................................................................46 Chapter 3 Discussion of Findings and Implications ................................................................ 48 Educating for Practice when WPV is the Norm ......................................................................48 Shifting the Culture of Practice ..............................................................................................51 New Avenues for Research ...................................................................................................53 Limitations .............................................................................................................................54 Summary...............................................................................................................................55 Chapter 4 Conclusion and Recommendations ......................................................................... 56 Perceptions of Not Feeling Prepared .....................................................................................56 Institutional Contributions to WPV .........................................................................................56 Implications and Recommendations for change ....................................................................57 Education and Support ......................................................................................................58 Revision of Organization Structures ..................................................................................59 Summary...............................................................................................................................59 Conclusion ............................................................................................................................60 References .................................................................................................................................... 61    5 LIST OF TABLES Table 1: Chronological overview of articles included within the Integrative Literature Review ……………..…………………………………………………………………14    6 CHAPTER 1: BACKGROUND AND RESEARCH QUESTION Introduction and Background The notion that new nursing graduates (NG) encounter workplace violence (WPV) during the first year of practice has been identified in the literature as a normalized part of their transition into the work environment (Curtis, Bowen, & Reid, 2007; Duchscher & Myrick, 2008; B. G. McKenna, Smith, Poole, & Coverdale, 2003; Russell, 2005; Vessey, DeMarco, Gaffney, & Budin, 2009). Workplace violence in the nursing profession is prevalent worldwide: international studies have reported rates of WPV of 57% in Australia, 37% in Scandinavian countries, the US and UK (Duchscher & Myrick, 2008). Duchscher and Myrick (2008) report that 33-61% of new Canadian RN graduates also experience this phenomenon, leading those affected toward either changing their employment environment or exiting from the nursing profession all together.   Nurses tend to be more at risk of workplace violence than other industry professionals (Bentley, Catley, Forsyth, & Tappin, 2014; Magnavita & Heponiemi, 2011). This violence can be experienced from patients, visitors, and coworkers within the healthcare organization.  The concept of workplace violence is generally used both in the literature and by nurses to describe aggressive or violent behaviours arising from conflict.  Violence consists of offensive, abusive, and intimidating behaviours inflicted by one person on another. The recipients are often left feeling humiliated, vulnerable, and threatened (Vessey et al., 2009). Of the various potential sources of violence nurses face, this paper specifically will be addressing violence arising within relationships between nurses.   Workplace violence, variously referred to in the literature as horizontal violence, bullying, intra-professional violence or lateral violence, is the term used currently in various industries when referring to the concept of violence in the work setting (Hutchinson & Hurley, 7 2013).  This SPAR paper uses the term ‘workplace violence’ to describe and refer to violent behaviours between coworkers, more specifically amongst nurses.   Exposure to violence at work is effecting nurses both professionally and personally; threatening nurse retention, personal wellbeing, workplace morale and patient safety. Vessey et al. (2009) stated that the physical and emotional stresses of workplace violence including depression, anger, decreased self-worth, fear, weight loss, irritability, and self-doubt have prompted many nurses to consider leaving their workplaces.  Workplace violence unfolds within a culture of silence. Nurses generally choose not to report WPV for fear of retaliation or due to a lack of confidence in their institution’s support (Magnavita & Heponiemi, 2011; Vessey et al., 2009).  The organization may not empower or support nurses in ways so that they feel comfortable challenging WPV.  As Bentley et al. (2014), Hutchinson, Vickers, Jackson, and Wilkes (2010) and Magnavita and Heponiemi (2011) concur, workplace violence is linked to an organizations' failed system instead of to the individual traits of the employee experiencing violence. The literature supports that workplace violence within the nursing profession poses grave issues for the health care system, leading to poorer work performance, greater absenteeism, professional disengagement, and rapid job turnover (Magnavita & Heponiemi, 2011; Vessey et al., 2009).  These effects disenfranchise new NGs entering into the profession and ultimately alter the delivery of safe patient care.  This culture of silence may serve to perpetuate conflict and violence, a phenomenon to which new nursing graduates may be particularly vulnerable.   Significance and Research Questions As a clinical educator, I am well aware that NGs represent the future of nursing.  I have witnessed and experienced workplace violence during my career as an educator and struggle 8 with how to build collaborative supportive learning environments that adequately prepare NGs for workplace realities.  Given that we know that workplace violence amongst nurses exists (Curtis et al., 2007; Magnavita & Heponiemi, 2011; B. G. McKenna et al., 2003; Vessey et al., 2009), what is now required is research on the quality and appropriateness of nursing education to prepare NGs to avoid and manage difficult situations of actual and potential workplace violence. In this review, I am not suggesting that WPV is normal or inevitable.  However, current statistics and literature suggest that in contemporary health care contexts WPV is happening within and between nurses (Sanner-Stiehr & Ward-Smith, 2017; Statistics Canada, Health Canada, Canadian Institute for Health Information, 2006). Nurse educators have a responsibility to help NGs identify that this problem exists so that they can be prepared to contribute to prevent WPV and to act when it occurs.  NGs enter the nursing profession at a vulnerable stage of their career and the impact of exposure to WPV can be overwhelming.  Enabling NGs to be better prepared to respond to and challenge WPV effectively should be a part of their education.  My overall goal in this project was to explore how existing literature addresses the issue of NG readiness for the possibility of WPV, with particular interest in how institutional structures and the power dynamics generated by them serve to create and sustain WPV in nursing workplaces. The intent of this SPAR paper is twofold; 1.) to review and analyze current literature including peer reviewed and conceptual work that focuses on the readiness NGs experience for actual and potential workplace violence, and 2.) to explore and analyze literature addressing the contextual and relational aspects contributing to workplace violence in order to inform educators, such as myself, on how to adequately prepare and ready NGs for preventing, avoiding and dealing with workplace violence.  The paper's findings may be useful in nursing education programs, challenging educators to take a closer look at current curriculum and whether 9 educators are providing relevant strategies for NGs to shape and respond to the realities of the workplace.   This SPAR paper aims to increase understanding of NG’s readiness for the potential of workplace violence.   In this paper, the term “readiness” is used to refer to the extent to which NG’s education has provided knowledge and skills to assist new nurses to help build a positive workplace environment, to help new graduates identify and respond to potentially violent situations and to prepare them for encounters with workplace violence in the first year of their profession.   In the literature “readiness” is used interchangeably with other terms such as preparedness and transition. The notion of “readiness”/"preparedness”/“transition” has been examined in the literature within the context of clinical practice, clinical skills and clinical knowledge (Andrews, 2013; Kelly & Ahern, 2008; Pellico, Brewer, & Kovner, 2009; Phillips, Kenny, Esterman, & Smith, 2014; Walker & Campbell, 2013; Wolff, Regan, Pesut, & Black, 2010).   The idea of ‘readiness’ refers to the nurse’s clinical knowledge, skills and experiences generally, and rarely addresses the extent to which they are ready to prevent or respond to WPV specifically.  This SPAR paper focused on literature regarding NGs readiness to practice within current work environments, specifically, their readiness for situations of potential and actual workplace violence. Following this section, I outline the methodology used for this review, that is, an integrative literature review. The chapter ends with an overview of the particular conceptualization of power that has guided this review. In Chapter 2, I report on the findings from the integrated literature review.  10 Methodology The integrative literature review methodology was used for this paper. Russell (2005) describes the integrative review as a review method that summarizes empirical or theoretical literature in an effort to better understand health care phenomena. This methodology has many benefits including evaluating the strength of the scientific evidence, identifying gaps in current research, and identifying the need for future research (Russell, 2005). Rather than being focused primarily on one type of study design, the integrative review allows for a variety of methodologies to be explored, which allows for the inclusion of multiple perspectives on a topic (Whittemore & Knafl, 2005). Using findings from various methodological approaches may support a broader understanding of the phenomenon being researched.  The various research purposes and approaches that an integrative review draws upon has the potential to result in a more comprehensive understanding of complex concepts and health care issues that are of importance to nursing  (Whittemore & Knafl, 2005). This is why this methodology is advocated as important to nursing science and nursing practice and was chosen for this SPAR paper.  Examples of the types of research that may be included in integrative reviews include: experimental and non-experimental research, as well as theoretical and empirical literature. There are five stages when using an integrative review as the chosen methodology, they include: problem identification, literature search, data collection and evaluation, data analysis and presentation (Whittemore & Knafl, 2005). The use of this approach, and following these steps and stages, guided the way in which I carried out my analysis. For the first stage of problem identification, I have identified that NGs tend to find themselves in a vulnerable position as they enter the nursing profession.  NGs vary in the extent to which they are prepared for the potential or actual WPV that may exist in their workplaces. Through an integrative review process, my research question addressed the potential readiness of 11 NGs for actual and potential workplace violence.  This review focused particularly on literature that addressed WPV as contextually and relationally created and sustained as a feature of NGs’ workplaces.  For the literature search, which is the second stage of an integrative literature review, a systematic search approach (as described below) was applied to search for all studies relevant to the topic of the NGs and their preparedness for WPV situations.  The third stage involved the selection of the relevant studies with the target population of NGs practicing in the profession for up to and including one year.  The selection of studies included in the review and the analysis of the findings from these selected studies will be discussed in detail in chapters 2 and 3. A summary of the research approaches used in these studies will be described later in this chapter (Table 1). The final stage will be further covered in Chapter-3, including a discussion of the main findings and implications drawn from the review in regard to informing educators on how to more adequately prepare and ready NGs to deal with WPV.  Chapter 4 will include a conclusion and recommendations that may challenge educators to take a closer look at current curriculum and whether educators are providing relevant strategies for NGs to shape and respond to the realities of the social climate in the workplace.   Search Strategies My goal in the literature search for this SPAR paper was to draw upon evidence based platforms with peer-reviewed research and conceptual papers that addressed my project question. The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, ERIC and EMBASE were used to investigate the posed questions.  A combination of the key words and index terms such as; “bullying” or “intra professional violence,” or "violence", or “intra professional conflict,” and “new graduates,” “novice nurses,” or “new nurses” was applied in the 12 search strategy.  Search terms were used in combination with one another to obtain articles relevant to my posed questions.  Inclusion criteria included articles related to my population of focus -- nursing graduates -- who have been nursing for up to one year.  Exclusion criteria were articles that focus on other types of violence, for example inter-professional violence or patient against nurse violence.  This exclusion criteria helped confine my search for articles that pertain to my posed questions. The SPAR paper aims to systematically examine available conceptual and research literature hoping to find pertinent evidence to address the posed questions.  The initial search of the four databases using the above index terms resulted in the identification of 36 articles.  However, after careful examination of the articles, only nine studies met the inclusion criteria and related to this review’s main research questions.  These nine studies are the focus of the integrative literature review (see Table 1).  Initially, in my efforts to find a diverse and adequate number of relevant articles, I included articles written in English that were published within the past ten years and not exclusive to North America. Although the Canadian context is of most relevance to the objectives, I found no empirical studies directly addressing Canadian NGs’ readiness for the actualities of current workplace settings. Most of research that met search criteria for this integrative review is from Australia and the United States.  Although there are many parallels between the Canadian context and that of these two countries, there are also important differences. The one Canadian research article (Duchscher, 2001),  brought some insight into the Canadian context. The integrative review’s findings will need critical consideration for their relevance to the Canadian context for results to usefully inform nursing educators and leaders in this country.  13 My intention in this project was to exclude literature older than 10 years. However, three studies (Duchscher, 2001; Hutchinson, Vickers, Jackson, & Wilkes, 2006a, 2006b) were included despite their earlier publication dates. Duchscher (2001) was included because of its Canadian context.  Hutchinson et al. have done foundational work on the topic of WPV from an institutional perspective and are viewed as landmark authors, and are frequently referenced by other writers.  Hutchinson et al. are often mentioned within other research as providing valuable insights into the possible organizational contributions relating to power disparities for the nursing profession.  In addition to the three articles above, six more articles were selected (Holmes, Murray, Perron, & McCabe, 2008; Hutchinson & Jackson, 2015; Hutchinson et al., 2010; Kelly & Ahern, 2008; Pellico et al., 2009; Phillips et al., 2014). This search resulted in nine relevant studies being selected and included for the integrative literature review. They are presented chronologically within Table 1. The papers reviewed were as follows: • two discussion papers • one analysis paper • two secondary analysis studies •  two qualitative phenomenological study • one first stage results from a larger mixed method study  • one cross sectional study 14 Table 1  Chronological overview of articles included within the integrative literature review    Study Title Authors Year Study Design/ Sample Size  Country Common themes  1. Out in the real world; Newly graduated nurses in acute care speak out Duchscher  2001 Phenomenological study  (n=5)  Canada • NGs felt unsupported and ‘trapped’  • assumption that support and respect would be given to NGs upon entry to the profession • NGs found the reality of the workplace quite different than what was expected 2. Workplace bullying in nursing: Towards a more critical organizational perspective Hutchinson Jackson Vickers Wilkes 2006a Discussion article Australia • the concept of power (organizational contexts) to explain existence of WPV • Foucault and power: disciplinary power is used in organizations  •  Mechanisms of control (surveillance/monitoring) serve organization’s interests • applies Clegg’s framework of “circuits of power”- the social integration form of power 3. “They stand you in a corner; you are not to speak”:  Nurses tell of abusive indoctrination in work teams dominated by bullies Hutchinson Vickers Jackson Wilkes 2006b First stage findings from a larger mixed method study: qualitative  semi-structured interviews n=26 Australia • bullying works at an organizational level  • also embedded within interpersonal alliances • WPV is enacted by nurses in teams who are • supported silently by the organization • indoctrination process happening that shaped the nurse unit environment  15  Study Title Authors Year Study Design/ Sample Size  Country Common themes  4.  Nursing Best Practice Guidelines: Reflecting on the obscene rise of the void  Holmes Murray Perron  McCabe  2008 Analysis paper Canada • Best Practice Guidelines as mechanisms of power • surveillance and self-monitoring serve as means for the nurse to keep align with the organization’s work doctrines 5. Preparing nurses for practice: A phenomenological study of the new graduate in Australia  Kelly Ahern 2008 Phenomenological study  n=13 Australia  • NGs were unaware of the existence of nursing “cliques” and how they operated  • NGs were unaware of the organizational power dynamics  • NGs felt disrespected by new colleagues 6. What newly licensed registered nurses have to say about their first experiences  Pellico Brewster  Kovner  2009 Secondary data analysis study survey method n= 612 United States • dominant theme found was NGs perceived they were mistreated by colleagues and this lead to high turnover  • NGs reported feeling unready for the social realities in the profession • NGs noticed and took offence to the silence from the organization on the power disparities that were occurring 7.  Bullying as Circuits of Power: An Australian Nursing Perspective Hutchinson Vickers Jackson Wilkes 2010 Discussion Article Australia • focus on organizational power dynamics • organizational climate fosters an environment that stems WPV • use of the “Circuits of Power” Framework by Clegg-organizational tolerance and reward/network of informal org alliances/misuse of authority, processes, procedures/normalization of bullying 16  Study Title Authors Year Study Design/ Sample Size  Country Common themes  8. A secondary data analysis examining the needs of graduate nurses in their transition to a new role  Phillips Kenny  Esterman  Smith 2014 Secondary data analysis study n=452 focus groups survey method Australia • NGs experienced lack of support, incivility and other WPV tactics in the transition phase of entering workforce • NGs felt unprepared for the social climate realities of their new work environments 9. The construction and legitimation of  wp bullying in the public sector: insight into power dynamics and organizational failures in health and social care Hutchinson Jackson 2015 Cross Sectional Study n=3345 survey method Australia • dynamics of institutional power and its impact on the occurrence of WPV • nursing employees constantly feel they are being monitored, disciplined, observed • organization environment draws a line between those who adhere and those who require “discipline”   17 Foucault’s Concept of Power It is vital to discuss the concept of power when critically analyzing WPV in nursing.  WPV is generally viewed as the abuse of power by individuals within a system, and consequently, how power is conceptualized will determine how the problem of WPV is approached. At a very basic level, power is defined in a concrete way as “the possession of control, authority, or influence over others” (Power, Merriam-Webster dictionary, 2017).  From a critical perspective however, I am interested in the contexts within which control, authority and influence that constitute WPV are generated and sustained, and how different perspectives on this underpin current literature on this topic. This requires a broader perspective on the concept of power.  As the above definition suggests, power can be understood as the exercise of influence of one person on another.  In this view, the focus might be on the individual’s personality and their assertiveness or conflict management skills (Purpora, Blegen, & Stotts, 2012; Roberts, Demarco, & Griffin, 2009).  Or, power can be looked at as a dynamic process that is generated between persons in every interaction.  In this case, power would be understood as a system issue (Farrell, 2001; Hutchinson & Jackson, 2015; Hutchinson et al., 2006b, 2010). This perspective on power leads us to examine the various reasons for the manifestations of power and view the actual incidence of WPV as a symptom of systemic issues.  The work of Foucault aligns with goals of this analysis because it supports a complex view of the concept of power, expanding attention beyond individual and group behaviour and toward complex, relational contexts within which power is manifest. Foucault challenges the idea that power is exercised by individuals or groups in discrete acts imposed by one on another, seeing it instead as pervasive – as a dimension of all human relations. In his view, ‘power is everywhere’ and ‘comes from everywhere’ (Foucault, 1990, p. 63). Drawing on Foucault’s work, 18 in this analysis, power will be examined using a relational approach, where power is multifaceted and dynamic.  There are multiple manifestations of power and they are most often embedded in social or cultural norms (Bradbury-Jones, Sambrook, & Irvine, 2008).   In thinking about power, many factors come into play that contribute to an individual’s relationship with power.  Gender, race, class, religion, sex, and age are some of the factors that shape an individual’s experience with power.  For instance, in a particular social context, women might be viewed by some as nurturing, emotional, and/or weak.  Through various mechanisms of power, women might be set up to accept inferior roles in society, creating unequal relationships.  This also can be illustrated in workplace environments, where systemic forms of power put some people at more of an advantage than others. Foucault states, “Power functions. Power is exercised through networks, and individuals do not simply circulate in those networks; they are in a position to both submit to and exercise this power” (Foucault, 2003, p. 29). He described power as a relationship between two individuals and that individuals can influence and control the behaviours of others.  He also described that the controlling of another person's behaviour was through strategic tactics; such as leading or guiding people to conduct themselves in specific ways (Foucault, 1983).  Foucault has been influential in pointing to the ways that norms can be so embedded they become taken for granted when in fact, the assumptions underpinning these norms can examined and questioned.   Foucault’s power analysis has been utilized to explain the power dynamics in the nursing profession and the organizations within which nurses are employed (Bradbury-Jones et al., 2008, Hutchinson et al., 2006b, Manias & Street, 2000, St-Pierre & Holmes, 2008). Foucault’s perspective on power is useful to understanding WPV in nursing because nurses work in complex systems where multiple layers of surveillance are at play. Some nurses are better 19 positioned to exercise power in relationships than others. In this analysis, this perspective on power led me to ask particular questions as I read and reflected on the existing literature on WPV. These included: • What perspective on power underpinned the author(s)’ notion of WPV and analysis? • How are the causes of WPV as portrayed in the article? • What do the author(s) propose as potential solutions to the problem of WPV, and in what ways do they account for power as a complex and relational phenomenon? In this SPAR paper I will use Foucault’s views on power to offer a new perspective that may help NGs develop new insights into some of the dynamics of the profession, better understanding of how to position themselves, act, and support a different view of the profession.  Instead of seeing themselves as victims, the hope is that new NGs will recognize they have choices and can offer possibilities in creating healthy work environments where WPV is no longer tolerated.  This critical perspective can also inform nursing leaders and educators as they seek to support new graduates when they enter the profession, possibly enhancing the retention of new nurses, and creating ethically sound workplaces. Summary  In this chapter I have outlined the plan, research questions, methodology and key concept of power guiding this integrative literature review. The subsequent chapters will explore the eight research articles included in this literature review in order analyze what is currently known about the topic (Chapter 2). Subsequently I will discuss the implications of the findings and potential next steps (Chapters 3 and 4).  20 CHAPTER 2 ANALYSIS OF FINDINGS FROM THE LITERATURE REVIEW In this chapter I present and analyze the eight studies selected for this review. I begin by reviewing each according to the primary research question focusing on the readiness NGs experience for actual and potential workplace violence. I then examine the literature addressing contextual and relational features of workplaces that contribute to workplace violence.  Using the analytic questions posed, the analysis aims to understand more about organizations’ contributions to WPV and the effect of these on nurses’ workplace experiences.   Introduction The available literature approaches the issue of WPV from a variety of theoretical perspectives. These different perspectives lead toward dramatically different answers about how the issue should be understood and addressed. In this section I present an analysis of the literature chosen for the integrative review, analyzing it from a critical perspective. My overall goal is to explore what the literature offers to support new graduates as they enter the workforce and consequently focus on how institutional structures and the power dynamics generated serve to create and sustain WPV in nursing workplaces. While this perspective more closely aligns with the critical perspective I have assumed, my analysis draws attention toward both the strengths and limitations of adopting the recommendations from these authors assuming this viewpoint. The two themes that I identified are:   1. NGs were unprepared for WPV, mistreatment came as a surprise 2.  Organizations have institutionalized WPV Theme 1: NGs were Unprepared for WPV, Mistreatment Came as a Surprise Nurses are exposed to various types of abuse from sources that include patients, visitors, nurses, physicians, or others in the healthcare work environment. In fact, new NGs can expect to 21 experience some form of WPV within the first year of entering the nursing profession (Curtis et al., 2007; Duchscher & Myrick, 2008; Magnavita & Heponiemi, 2011; L. G. McKenna & Green, 2004).  As described earlier in this paper, because they are new to practice, and relatively new to the cultures of practice units, NGs can be particularly vulnerable to the negative effects of WPV.  The fact that NGs need a high level of support and guidance as they embark on their new professional role is well established. However, this need for support and guidance might also increase their vulnerability in environments where efficiency is highly valued, and the time taken to provide support is undervalued (Kelly & Ahern, 2008). From this perspective, attention to the structure of nursing workplaces (including the structures that shape power dynamics) is very important. This is the topic I address in the theme.  Preparation of NGs to understand and manage WPV is the primary approach to this problem.  In this section I explore literature addressing this issue of preparation. In searching the literature, a gap in the research was discovered relating to whether or not NGs are ready for actual or potential WPV.  Much of readiness for practice literature focuses on NGs overall transition; addressing topics such as socialization, clinical knowledge and professional development (Andrews, 2013; Heslop, McIntyre, & Ives, 2001; Kelly & Ahern, 2008; Pellico et al., 2009; Phillips et al., 2014; Rush, Adamack, Gordon, & Janke, 2014; Teoh, Pua, & Chan, 2013). Within this literature, however, the topic of NGs and WPV tends to arise in the context of the more general topic of nurses’ transition from student to graduate nurse. Of particular importance to this review are the recurrent findings that NGs struggled to understand and negotiate power dynamics, a challenge that put them at a disadvantage during the initial period of socialization within the workplace (Kelly & Ahern, 2008; Pellico et al., 2009; Phillips et al., 2014).  22 Lack of Support and Respect   Phillips et al. (2014) conducted a secondary data analysis of a data set from a larger Australian study examining undergraduate paid employment choices and the relationship of these to student nurses’ transition to their positions as graduate nurses. During the initial analysis of the larger original study, most of the qualitative data pertained to factors that affected transition. This led the authors to conduct a secondary data analysis of NGs (n=452), exploring what factors graduate nurses believe assist in successful transition to registered nurse practice.  In their exploration of graduate nurses’ beliefs about transition to practice, Phillips et al. (2014) found that most NGs reported a lack of support and respect during their early days in practice. In general, NGs described their initial expectation that their more experienced nursing colleagues would support them in the adjustment phase, providing constructive feedback so that they could gradually gain knowledge experience. However, instead of support, many of the participants reported experiencing various forms of violence including constant scrutiny as well as direct and indirect undermining of their work. Most participants described this lack of support as arising from the organization and from their colleagues. Some of the participants believed they were set up in a way to fail: ineffective orientation processes, lack of designated preceptors or mentors, heavy workloads, and insufficient time to utilize available supports undermined their goals of success in their transition to registered nurse.   Moreover, in this study, lack of respect from colleagues emerged as a major factor that undermined confidence and motivation to continue working (Phillips et al., 2014). Those nurses who were not supported in the socialization process tended to be less satisfied, performed poorly and were less committed to the organization. Phillips et al. found respect was crucial for NGs --  it helped put them in a position of social acceptance within their new work environment.  The 23 work completed by these authors illustrates the importance of social acceptance for NGs, ultimately leading them either to success or hindering them from pushing onwards if the work environment is not a positive experience.  The part of this study that links back to this SPAR paper is that the NG participants admitted to researchers they were not prepared for the reality of working in today’s nursing culture.  The social actualities of the nursing working environment came as a surprise and because they did not have sufficient experience with managing unsupportive behaviours: NGs felt helpless in addressing the workplace incivilities (Phillips et al., 2014). The authors of this paper do not comment on the power dynamics inherent in their themes related to social acceptance, respect, and support, and only briefly allude to the importance of structural features that shape NGs experiences. However, the identification of key themes in new graduates’ experiences may provide useful insights into sites for action for nursing leaders and educators.   As mentioned earlier, there is a lack of Canadian literature addressing NGs’ readiness for experiences of actual and potential WPV.  According to the 2005 National Survey of the Work and Health of Nurses (Statistics Canada, Health Canada, Canadian Institute for Health Information, 2006), in Canada, 44% of female nurses and 50% of male nurses report exposure to hostility or conflict in their workplace.  These statistics confirm that Canadian nurses also experience WPV making the issue of NG’s readiness is relevant here.   In the one Canadian study that met the search criteria (with its expanded date scope), Duchscher (2001) explored NG’s experiences in their first six months of practice. Using a phenomenological approach, she interviewed NGs recruited from three acute-care hospitals in a mid-sized Canadian city.  The findings provide similar insights as Phillips et al. (2014) and Kelly and Ahern (2008) in relation to the socialization and professionalization processes of new NGs.  24 Duchscher’s participants described the challenges these they faced including a workplace context of criticism rather than acceptance: "Some nurses aren’t too nice, they’re not too helpful... Other ones, they just kind of make a list of everything you didn’t do or didn’t do correctly” (p. 429). This context of criticism occurred in a setting where they felt unsupported and ‘trapped’ by the new overwhelming responsibility of the job while receiving little or no assistance from more senior staff. The assumption that support and respect would be given to them by their colleagues upon entry to the profession echoes similar themes from the Australian literature (Phillips et al., 2014 and Kelly & Ahern, 2008) – they longed for acceptance and support from by nursing staff and found the reality of the workplace quite different. This study highlighted the importance of strong, supportive mentoring relationships for NGs and demonstrated the disappointing work environment realities waiting for new nurses when they enter the profession.  There are serious limitations to Duchscher's (2001) Canadian study. As a phenomenological study, the sample size was small (n=5) and the findings are not intended to be transferable to other settings.  Duchscher’s prior involvement as a nursing educator with two of the five participants will have shaped the findings and this needs to be taken into account when considering relevance.  The power dynamics between nurse educator and student may have influenced the participants’ responses and influenced the result in this way. These issues reduce its comparability with the Australian research presented earlier.  Nevertheless, this does demonstrate the need for further Canadian research examining NGs' experiences of negotiating and managing WPV in the health care system. Nursing ‘Cliques’ and Power Games In another phenomenological study on NG readiness, Kelly and Ahern (2008) found similar themes to those of Philips et al. (2008). The aim of this  Australian study was to explore 25 new graduates’ experiences as they transitioned from students to new graduates. Semi-structured interviews were conducted with 13 final semester students enrolled in a Bachelor of Nursing degree at an Australian University. The first interview was conducted prior to commencing employment. Each participant was interviewed twice, first at one month after initiation of employment and subsequently at six months into their employment.   Several relevant themes related to WPV were identified in Kelly and Ahern’s (2008) analysis.  Within the nurses’ accounts were descriptions of the challenges they faced as they entered the workplace – challenges for which they generally felt poorly prepared. Specific themes such as those addressing the existence of ‘cliques’ point toward the patterns of power that shaped NG’s transition experiences. NG participants were not prepared for these features of their new workplaces, and overall, were naïve about the power dynamics that shaped these.  Prior to becoming nurses, the participants did not even perceive that ‘cliques’ existed in the workplace and had limited awareness of what the culture of the nursing profession entailed.  One participant commented, “There is a whole socialization process to conquer” (Kelly & Ahern, 2008, p. 913).   This study echoes the common theme that NGs may not be aware or ready for the cultural features of nursing work environments and that certain features of work contexts may negatively affect their transition experiences.  As was found in the Phillips et al. (2014), participants in Kelly and Ahern’s (2008) also depicted how the lack of respect and support experienced by NGs in their new places of work undermined their confidence and negatively affected their transition process. This lack of respect was manifest in several ways. For example, participants described specific language patterns that colleagues would use with NGs, a type of verbal communication that was rude and sharp, 26 creating self-consciousness and humiliation. In this way, the distinct nursing culture influenced their experience of socialization into the profession.   An important theme arising from this study related to the participants’ perception of power relations in a theme named by the authors as ‘power games’ (Kelly & Ahern, 2008).  Participants described how, prior to graduation, they had limited awareness of how power plays out within the workplace. Several of the participants in the study believed that they had not been prepared for issues involving power and as such were disadvantaged on their entry to the workplace. One respondent was “overwhelmed by the different personalities and attitudes of registered nurses”, and another claimed, “working with nurses was difficult” (Kelly & Ahern., 2008, p. 913). Although the authors do not specifically explore what the participants meant by power, these rather general findings suggest that the relational dynamics between NGs and more senior nurses can be the source of significant frustration for NGs.  In a discussion article, Eggertson (2011) describes similar experiences of WPV power relations among Canadian NGs.  Like Phillips et al. (2014) and Kelly and Ahern (2008), Eggertson describes destructive power dynamics between nurses within Canadian healthcare practice environments.  Eggertson presents the stories of nurses who were willing to share their experiences, and used these to highlight the statistics about WPV in nursing cited above.  Various nurses recounted the lack of respect, mistreatment from colleagues and subtle coercive behaviors that they frequently encountered in their workplace.  In one respondent’s story, a senior nurse refused to share information with a more junior nurse.  The senior nurse’s explanation was ‘I had to figure things out for myself; you figure it out, too’ (pg. 17). Another nurse interviewed by Eggerston’s spoke about an incident in a Toronto hospital, where a new graduate was berated for interrupting a staff meeting only to ask for support with a clinical 27 situation. In response to the question, the nurse team leader responds, “What’s your problem? Just take the report” (Eggerston, 2011, pg. 20).   While not an empirical study or a systematic review, this article by Eggerston (2011) draws attention to Canadian health care contexts, and the likelihood that many of the contextual features depicted in the Australian and American studies may have relevance in this country. Analyzing the limited Canadian literature, it becomes apparent that not enough relevant Canadian context research is being conducted on whether NGs have the appropriate skills needed to navigate complex workplace practice environments or how leaders may be addressing this issue. Mistreatment by Colleagues Pellico et al. (2009) presented findings from a secondary analysis of data from a survey study (n=612) exploring NGs’ experiences of their work life.  Data was collected by a cross-sectional mailed survey of NGs to 34 states and the District of Columbia, USA with the goal of obtaining a nationally representative sample. The city size variation was taken into account by randomly selecting from small, medium, large cities and rural areas.  The authors chose this method to maximize representation, aiming for a full range of health care delivery systems, community cultures, and economic differences.  Using content analysis, this secondary analysis explored factors that promote retention of NGs, and factors that contribute to turnover. Consistent with findings of the other studies described in this section, the dominant factor leading toward nurses’ intentions to leave their positions was the mistreatment they perceived by their colleagues. As with the two studies reviewed above, this analysis revealed that the NGs experienced incongruence between their 28 own personal expectations of nursing, professional behaviour and colleagueship and their experience of the actual world of nursing practice.  Pellico et al. (2009) also make reference to NGs perception they are poorly prepared for the social realities of practice in today’s nursing culture: “I wish someone would have prepared me for the natural ‘let down’ that happens after graduating from school. It’s a difficult transition” (p. 197). Amongst other factors in the workplace that failed to meet their expectations, NGs experienced abuse at the hands of their colleagues. NGs commented that they felt “nurses eat their young” (p. 199) and described colleague criticism was covert, harsh, and cruel.  The damage from abuse was compounded by the silence from the organization on this issue, as the NGs could not understand how management could fail to take action while nurses mistreated one another. The findings support the claim that organizations have a responsibility to create and maintain healthy work environments and that nurses believe organizations are not meeting this responsibility. Analysis of the Theme A common theme in these three studies (Kelly & Ahern, 2008; Pellico et al., 2009; Phillips et al., 2014) is that NGs feel unprepared to deal with aspects of the work environment that could be understood as WPV.  Although not named as WPV, taken together, these studies portray NGs experiences of being verbally abused, undermined and excluded from social groups at the same time as they feel unsupported within the organizational structure.  The findings of the above reviewed articles inform understanding of how power is enacted in nursing workplaces. Although most of the findings are not presented through a lens of power relations, bringing this lens to the analysis informs leaders and educators about potential targets for action to address the problem of WPV. Even though the articles used in this 29 integrative review do not purposely study the readiness of NGs for actual and potential WPV, they offer insight into NGs awareness and thoughts about the power disparities they are experiencing.  According to Foucault, power is everywhere (1977). It is manifest in relationships (including learning relationships) and shapes people’s behaviour.  Most NGs enter into the profession generally unaware of the complex power relations amongst nurses, or the use deliberate and taken-for-granted mechanisms that shape power relations.  Many NGs feel powerless and ill-prepared to negotiate the challenging situations in which they find themselves (Kelly & Ahern, 2008; Pellico et al., 2009; Phillips et al., 2014).  The literature demonstrates that the institutional structures of the organizations in which NGs come to work are not set up to allow critical questioning that opposes the entrenched status quo (Kelly & Ahern, 2008; Pellico et al., 2009; Phillips et al., 2014). Rather than experiencing respect, cooperation or collaboration, many of the NGs described feeling unsupported, undermined and alienated.  Ultimately, this could impact the retention of NGs and consequently the quality of healthcare due to an increasing nursing shortage.  How can NGs learn to be reflective, critical and an active part of the professional team if they are told as soon as they enter the profession to be obedient, quiet and submissive? The dominant power dynamics in a given clinical setting affect nursing practice within it, and ultimately NGs will work hard to fit in, especially if the organization does nothing to stop abusive behaviours but only is interested in maintaining the status quo (Pellico et al., 2009).  Teaching NGs to understand power as relational will help them critically examine power dynamics and contribute to creating healthier workplace environments.   30 Summary This analysis of literature addressing the readiness of NGs for the realities of the workplace exposes the fact that many NGs' experience some form of WPV and that they find themselves unprepared to deal with this reality. These are serious issues. This gap between nurses’ preparation and their experience has consequences for the nurse in terms of confidence and overall capacity to learn and practice optimally, for the organization and efforts to retain good nurses, and ultimately, for patients’ and the quality of nursing care.  These studies highlight the need for nursing programs to include concepts of nursing socialization in their curriculum so that NGs are aware and arrive to the profession more prepared to identify situations of potential and actual abuse, and to have the tools to address these. Further, the findings of these studies (largely indirectly) point toward the taken for granted aspects of organizations that shape power dynamics, and in many instances, create and sustain WPV.  Theme 2: Health Care Organizations have Institutionalized WPV In the analysis of the first theme, I highlighted the complexities of preparing nurses for a practice environment where certain forms of WPV have become the norm, and where power dynamics between NGs and more experienced nurses greatly shape NGs’ experiences. In this section, I focus on the dynamics of healthcare work environment and analyze literature addressing the organizational contexts of WPV. I present these as two subthemes as each has important implications for leadership, policy and research related to WPV and new nursing graduates. The first has to do with the complex and relational nature of institutional power, including a framework that has been developed to explore how institutional power relations perpetuate WPV. The second subtheme addresses two specific mechanisms of power that serve 31 to shape power relations and potentially encourage various forms of WPV: surveillance and indoctrination.  Organizational Structures Generate Work Environments that Promote WPV Taken together, two discussion articles by Hutchinson, Jackson, Vickers and Wilkes (2006b, 2010) provide a useful theoretical perspective on WPV from an institutional viewpoint. The articles focus on structures and processes of that shape “everyday constitutions of power in organizations” (2010, p. 32), and explore ways that these constitutions of power create conditions where WPV arises. Through these theoretical analyses, Hutchinson et al. strive to create a framework to explain how WPV arises and is sustained in contemporary nursing workplaces.  Hutchinson et al. (2006b, 2010) propose that conflict-based reasoning which has been used most often to explain WPV, fails to sufficiently explain workplace power dynamics, particularly how they serve to perpetuate WPV. These authors also depict the inadequacies of oppression theories in explaining WPV in nursing. Instead, they focus on the constitutions of power that exist within the organization. They understand WPV as repeated acts involving various mechanisms of power, in which one or more individuals engage in over time, with the intention to harm others and create hostile work environments (Hutchinson et al., 2010). In their work, Hutchinson et al. (2006b, 2010) focus mainly on the factors shaping the power relations in work environments. From their perspective, WPV is less a response to oppression and more a consequence of the organizational power dynamics that shape nurses’ work environments.  An analysis of these two discussion papers supports the notion that certain features of organizational climates may contribute to an environment that either supports or hinders WPV.  Worth mentioning here is Hutchinson et al.’s (2006b) perspective on power 32 dynamics in WPV. Taking a more critical perspective, they drew on Foucault’s (1977) theory of power that I have described earlier in this paper – a perspective of power as ‘diffuse and invisible, and [as] both a positive and negative force dispersed within social networks” (Hutchinson et al., 2006b, p. 120). This perspective on power, along with a commitment to values of fairness and justice shape the critique and analysis presented in these two papers.    The entrenchment of work doctrines.  Hutchinson et al. (2006b) provide a critical analysis of the existing theories of WPV as they relate to this issue in nursing workplaces. They suggest that although power has been long recognized as central to the problem of WPV, the concept of power has been under theorized and that this is a significant problem that has limited efforts to address the problem in nursing workplaces.  In their analysis, these authors attempt to explore problems not well answered by existing theories of WPV and associated theories of power. The authors investigate the idea that those who question policy or rules of the organization are seen as resisting the work setting environment.  Hutchinson et al. (2006b) propose that the organization maintains order in the work environment by dealing with those resisting the work doctrines.  Those in managerial positions use their positions to keep all in check with the organization’s agendas.  Hutchinson et al. (2006b) also suggest that taking advantage of position levels and legitimate authority in the organization is replicated amongst nurses in various positions.  Nurses in work groups model this type of WPV behaviour to keep one another in alignment so that work continues to flow accordingly and there is no upheaval to the status quo or entrenched work doctrines.  For example, a senior nurse could be humiliated or alienated by other co-workers for asking questions or trying to make changes in existing work processes.  Accepted organizational values 33 are reinforced by the rest of the work group in order to maintain rules, order and social memberships in the work environment. Power relations between nurses are complex and dynamic.  In an effort to develop a more useful framework for examining WPV in nurse workplaces, Hutchinson et al. (2006b) build on Clegg’s (1989) theory of power dynamics in organizations. Building on Foucault’s definition of power, Clegg theorized power in organizations as a constitutive force of social relations operating in three distinct interacting circuits. He described three ‘circuits of power’ -- episodic, dispositional, and facilitative -- that could be understood as force fields. He theorized that these circuits helped explain the dynamics by which power relations are enacted to produce obedience in organizations.  The episodic circuit of power exists at a micro level and unfolds as an agency power influencing people to do what they would not otherwise do, in other words operating in an episodic manner. Nurses become conditioned to complete day-to-day interactions related to the routine of work.  Nurses are coerced to adhere to informal rules of work that can be described as accepted behaviours, rules, rewards, and punishments. Hutchinson et al. (2010), explain that nurses in work groups maintain these rules and are able to control others providing them with the capacity to influence day-to-day interactions and resources in the work environment.  Nurses enforce the established and accepted rules of work, fostering a conditioned or non-thinking mode that allows WPV tactics of humiliation and alienation to seem like the norm, tactics which are used to control those who resist or question.  In this circuit, WPV is used to recruit nurses to adopt behaviours that maintain the accepted order dictated by the organization in order to accomplish the organizations goals.  34 Building on Clegg’s force fields Hutchinson et al’s (2006b) interpreted each in relation to WPV in nursing practice environments.  Clegg’s (1989) dispositional circuit exists on a macro level. This is where ideas or notions deemed by the organization appear as entrenched and are not questioned, but those ideas may not represent reality.  They are socially constructed meanings created to inform relations and legitimatize the organization’s authority. Hutchinson et al. (2010) see examples of this circuit in the nursing work environment where those who question norms or policy and procedures are labelled as troublemakers. The organization condones work group persuasions as a mechanism of silencing or enforcing adherence and thereby tolerates (or even encourages) acts of WPV. In this way, the organization maintains work flow and sustains social order in the nursing work environment.  The third circuit of power – the facilitative circuit -- is also macro level. Within this circuit of power the organization either empowers or disempowers their employees. Misuse of power dynamics in this circuit by those in authority through processes of discipline and reward sustain and normalize WPV (Hutchinson et al., 2006b).  The performance of nurses is judged by those who have power.  Intense scrutiny through formal and informal mechanisms of scrutiny compounds the stress experienced in the work of nurses, and in of itself becomes a form of WPV (Hutchinson et al., 2006b).  Nurses who demonstrate compliance with the organization’s power are generally accepted and rewarded by those in authoritative positions and accepted socially within the work group.  Through this process a work atmosphere is created where nurses constantly monitor one another and may become uncritically compliant to the organizations processes and goals. This dynamic of uncritical acceptance of taken for granted work processes as well as methods of scrutiny and discipline could be deemed necessary so that individual nurses can fit in and survive the work environment. 35 This paper by Hutchinson et al. (2006b) provides a useful critique of previous literature on WPV in nursing. They brought an expanded view of power to the analysis of WPV in nursing that opens up new avenues to addressing this problem. The limits of individualistic understandings of power. The second discussion paper by Hutchinson et al. (2010) extends their earlier work, exploring the concept of power in more depth, further critiquing existing theories of WPV and developing a framework for testing their understanding of the intersections between institutional power dynamics and WPV.  The authors highlight the problem of the emphasis on production and efficiency that characterizes contemporary healthcare organizations.  They argue that the power dynamics needed to achieve this production allow the use of WPV tactics amongst the nursing profession.  Socially constructed rules within the nurse work teams condone and perpetuate violence while the organization remains silent, normalizing the legitimacy of these behaviours. This allows the organization to continue running as a productive, efficient and enforcing institution, no matter if the means are a contradiction to the core values of nursing, such as providing nurturing and optimal patient care.  Hutchinson et al. (2010) propose that power should not be looked at in conventional methods of hierarchy nor explained by personality differences or as arising from chaotic work environments. Individualistic perspectives interpret power as a force by certain people to exercise control over others (Hutchinson et al., 2010). The authors found instead that bullying is an institutional form of violence used to coerce and influence employees. The authors do not discount other views of the causes of WPV, but ask readers to consider that possibility that the power dynamics that constitute to WPV unfold not only at the surface level, but also very deep within the structure of organizations. 36 Hutchinson et al. (2010) identify features of the organizational climate that breed an environment for WPV.  Based on their analysis, the authors propose a framework for interpreting WPV using Clegg’s (1989) the circuits of power theory as a means to provide guidance for their future studies.  Such factors as organizational misuse of authority, organizational tolerance of WPV, reward to those who follow the rooted work doctrines, and networks of informal organizational alliances help the organization influence employees to follow the way they want things to run.  These factors could have a synergistic effect on WPV, in that the presence of them within the organization increases the likelihood of WPV to be accepted and keep occurring.  Analysis of the common theme. Through these two papers, Hutchinson et al. (2006b, 2010) build a useful conceptualization of power for considerations of WPV. The authors maintain that organizational characteristics of tolerance and reward, the misuse of legitimate authority, processes, and procedures, and the normalization of bullying in work teams are features that hinge on misused mechanisms of power and that these perpetuate WPV. This perspective casts new light on how power relations are structured and sustained by organizations to keep employees in line with workplace processes and used to ensure employee obedience.   The theorization of power and WPV in nursing by Hutchinson et al. (2006b, 2010), expands attention from a sole focus on individuals and groups and points toward clearer understandings of how institutional structures create the conditions where WPV unfolds.  In their definitions of power, Hutchinson et al. have drawn on Foucault’s notions that power is ubiquitous and relations, and that only be seen in everyday interaction and activities. There is some tension between this perspective on power and Clegg’s (1989) theory of circuits of power (which, as mentioned, underpins Hutchinson’s framework). Specifically, the metaphor of circuits suggests that power flows from an area of more power to an area of less power. In spite of this 37 tension, Hutchison et al.’s work extends previous work on WPV to include a much broader understanding of the factors that create the conditions where WPV occurs.  The analysis by Hutchinson et al (2006b, 2010) suggests that through more democratic work environments where organizational characteristics and their influence on WPV are brought into focus, educators should address the experiences of NGs on entry to the workplace, and open up new avenues of addressing issues of recruitment and retention of NGs. One avenue may be by creating processes to critically review organizational socially constituted rules, exploring the assumptions embedded in these and alternatives. These kinds of processes would support nurses’ efforts to practice in a way congruent with what is taught as being a part of the nursing profession.  The question is how can nursing move from this rather abstract notion of change to concrete action supporting the reworking and restructuring of organizations so that WPV is no longer promoted and tolerated? The benefit of using Clegg's circuits of power theory by Hutchinson et al. (2006b, 2010) is that it allows for power to be understood from different viewpoints, analytically as moving through three distinct circuits.  Clegg can be likened to Foucault in this regard, as they both seek to explain power using multiple levels and contexts.  This provides alternative understandings of the operation of power within organizations and gives way to using a critical perspective when examining WPV.  One important thing missing from Hutchinson et al.'s (2006b, 2010) analysis are strategies or steps of where to proceed next.   Summary. As emphasized and described above using these two analytic papers, organizational power dynamics influence WPV through facilitative circuits of power that control actions and enforce work doctrines.  This constitution of power dynamics within the organization enables some individuals to dominate and exercise WPV tactics, perpetuating an overall 38 adherence without questioning the bullying (Hutchinson et al., 2010). Switching perspective from oppressed group theory (individualistic) to the concept of power and circuits of power (organizational contexts) widens the lens for explaining the existence of WPV.  Work rules constructed in any organization should be open to review and interpretation, otherwise WPV will continue to be tolerated (Hutchinson et al., 2006b).  New nursing graduates may fail to notice the impact of prevailing health care ideologies on their practice and then also perpetuate the status quo by accepting WPV behaviours, and even reproducing such behaviours themselves (Hanson & McAllister, 2017).  There is a need to critically examine the organization’s perpetuation of WPV as it can help to alert new NGs that they have potential to resist work processes or behaviours that do not exemplify core values of the nursing profession or healthy workplace environments. Organizations use Normalization and Surveillance to Sustain WPV In the previous section I analyzed literature by Hutchinson et al. (2006b, 2010), highlighting their contributions to a broader understanding of the structural influences on WPV. In this section I explore literature specifically exploring two mechanisms within organizations that may contribute to WPV within health care work environments. These two mechanisms may shape power relations at all levels of an institution: the normalization of WPV and practices of surveillance.   WPV becomes normalized into everyday practice.  Multiple authors have described how various forms of WPV can become accepted as normal within an organization, by individuals, and within the nursing profession itself (Matheson & Bobay, 2007; Purpora et al., 2012; Roberts et al., 2009).  Foucault (1977) depicted ways in which institutional power dynamics can condition individuals to take for granted existing conditions, accepting the current 39 state of affairs as normal, or even as the way it should be. The goal is the normalization of existing practices, which is generally accomplished by various forms of indoctrination and coercion. Normalization relates to processes by which various forms of WPV become taken for granted in the workplace. Nurses tend to associate WPV as another challenge in their role that needs to be endured in order to earn respect and credibility for the job.   Nurses come to tolerate, accept and expect WPV. In a qualitative study  Hutchinson et al. (2006a) describe ways in which nurses tolerate, accept and anticipate WPV. The authors reported the qualitative findings from their first stage of a large national study (n= 26) on violence in the nursing workplace. They found that nurses formed informal alliances to gain and sustain control, determining some rules and enforcing others.  This type of WPV tends to be bottom up rather than top down (Hutchinson et al., 2006a).   The authors depict the normalization of WPV through enforced hierarchical divisions of labour; specifically, through informal alliances who ignore, deny, and minimize their violent behaviour, indoctrinating nurses into the organization's defined ‘rules’ of work’.  These rules of work were often unspoken yet legitimized within the practice context. For example, one nurse who was part of an informal alliance that wanted to take their breaks at a certain time, instead of discussing this with the nurse's assignment partner, the break times were dictated to the assignment partner. The nurse who is not a member of the informal alliance learns to accept this behaviour, “It’s just part of how it is” (Hutchinson et al., 2006a, p. 326); individuals were ‘obliged to obey’ (Hutchinson et al., 2006a, p. 354).  The day-to-day routines are controlled and operated by the dominating nurse group in order to remain in powerful influential positions within the organization. 40 Power dynamics are manifest in informal alliances. Hutchinson et al (2006a) found that these indoctrination processes that were upheld by informal alliances consisted of nurses who work in teams were silently supported by the organization.  Management supported the nurse groups’ WPV tactics by blaming those who did not follow as "weak" or "bad" nurses and rewarding those who followed by not reprimanding their behaviour (Hutchinson et al., 2006a).  This serves to reinforce and sustain WPV, particularly the subtler forms of it through these practices of indoctrination into the work environment.  The authors found that bullying worked at an organizational level but was also embedded with interpersonal alliances.  They described WPV as a form of organizational behaviour that was tolerated by hierarchical observations of individuals in the organization (Hutchinson et al., 2006a).  The acceptance of WPV by the organization strengthens the power of the nursing groups, protecting their positions, and perpetuating the violence. Hutchinson et al. illustrated how WPV is tolerated and becomes part of the indoctrination process in nursing teams.  The normalization of WPV by the organization allows this unacceptable behaviour to become a standard and acceptable. The findings in this paper foreshadow Hutchinson and colleagues’ subsequent work and their further exploration of the relational dynamics of WPV in nursing workplaces (Hutchinson et al., 2006a, 2006b, 2010). The authors believe that bullying works at an organizational level but becomes embedded within interpersonal alliances or cliques.  They describe WPV as a form of organizational behaviour that is tolerated by hierarchical observations of individuals in the organization (Hutchinson et al., 2006a).  The formation and maintenance of informal alliances (that are not necessarily manager level nurses) instigate control and promote the normalization of formal and informal ‘rules’. Analysis of common theme.  Hutchinson et al. (2006a) describe processes by which certain forms of WPV have been normalized in nursing workplaces.   Through processes of 41 control and indoctrination, nurse groups shape how individuals in the work setting think of themselves and in the process, coerce them to use WPV as well, maintaining the status quo. Foucault (1977) describes indoctrination as a sort of imprisonment, where individuals involved in a community (in this case the nursing profession and nursing workplaces) take what happens for granted and take what goes on as normal. In this way, normalization is a form of institutional power.  This constitution of power relations amongst nurses serves to normalize WPV as routine and legitimate work practices (Hutchinson et al, 2006a).  The indoctrination of WPV into the nursing culture has consequences for new graduates, in that they start to think that it is part of the job, and may succumb to similar behaviour patterns (Farrell, 2001).  This acceptance of informal rules to abide “or else…” demonstrates the powerful indoctrination process happening in the profession, and one of the means by which normalization occurs.  New nursing graduates require guidance to ensure proper socialization into the profession (Kelly & Ahern, 2008; Pellico et al., 2009; Phillips et al., 2014).  If there are insufficient role models available, NGs will generally take up the current principles of the unit rather than practicing their ideal conception of nursing. Surveillance serves to entrench rules and practices. The misuse of mechanisms of power in institutions may arise when practices that monitor, discipline, and observe (Hutchinson & Jackson, 2015) entrench certain rules and practices into the everyday life of nurses.  Certain features of the nurses’ working conditions could be described as covert forms of institutional violence. Surveillance tactics of discipline and monitoring, create work atmospheres that focus on worker efficiency and production.  The competition for results erodes the team work environment, drawing lines between those who adhere to the organization’s mandate and those who do not (Hutchinson & Jackson, 2015).  Where these conditions arise, the organization tends 42 to marginalize those who do not commit to the organizations rules and practices.  This dynamic tends to generate environments where WPV is tolerated and promotes a mentality of support for an organization and staff to use WPV tactics to coerce others.    Disciplinary power refers to the various techniques designed to regulate individuals’ thoughts and behaviours in order to make them act in specific ways for a specific purpose (Foucault, 1977).  Use of disciplinary practices in organizations constitutes a form of institutional violence. In his book Discipline and Punish, Foucault (1977), claims that discipline becomes a method of domination that results in subjugation or enslavement of individuals. He describes how relationships of power operate through institutional rules, tactics and systems (St-Pierre & Holmes, 2008). In applying Foucault’s work on discipline to the nursing profession, St-Pierre and Holmes (2008) show how healthcare institutions control their employees to achieve greater efficiency by creating work environments that reward obedience and acquiescence. These practices however, serve to undermine individual agency and may in fact lead toward poorer nursing care.  Surveillance practices monitor and discipline nurses’ behaviours. Recent work by Hutchinson and Jackson (2015) presents their analysis of data from a large scale (n=3345) cross sectional survey exploring the WPV experiences and beliefs of health and social care professionals. They drew on Foucault’s perspective on power dynamics within institutions, focusing their attention to institutional power dynamics, including surveillance tactics that were implicated in WPV. They found that WPV surveillance practices functioned as a method to intimidate individuals to follow their organization’s rules and policies.  Any nurse who dismissed or questioned an established formal policy might put themselves in a vulnerable position, inviting scrutiny and discipline from the organization as well as from their coworkers.  For 43 example, a NG questioned the unit’s policy on nurses floating to other units.  The NG asked if they could be excused from floating because they are new to the unit and feel the need to establish their clinical competency on the unit.  The charge nurse refused to listen to this NGs point of view and reasoning, only stating the policy is that this NG is the next to go on the list for floating and that if they do not abide disciplinary actions will follow.  Unknown to the NG, the charge nurse did not want to make the next nurse on the list float because they were more senior and a long-standing peer.  The NG's request was refused not based on legitimate grounds but rather to maintain the status quo and keep a more senior colleague content.  This approach erodes the legitimacy and respect of individual nurses, dividing the nurse team members through fear.  Nurse groups are molded to identify and subscribe to the organization’s rules of work, or be left to experience disciplinary consequences (Hutchinson & Jackson, 2015).   Hutchinson and Jackson (2015) found that, in order to survive the work environment, nurse groups tend to comply with organizational indoctrinated rules, applying control within group by utilizing discursive surveillance tactics. Discursive surveillance tactics are those practices that result in stigmatization of the target nurse. Thus, bullying served to influence the relations of meaning between workgroup members. Eroding legitimacy and respect, it divided team members through fear of their own experience of discursive surveillance and fear of having their reputation damaged by this subtle but powerful form of vilification. An example of this subtle form of WPV is in the situation where the nurse finds an error in patient care and instead of speaking with their co-worker primarily for clarification, the nurse fills out an incident report – the accepted protocol demanded by the organization.  The incident is then brought up to the offending nurse at a later time with only the leadership team present, the offending nurse is left feeling as if they were a “bad” nurse and that their co-workers share this 44 perspective. As a mechanism of this control, this incident reporting system leads nurses away from constructive feedback processes, and individual nurses are left feeling alienated, disciplined and disrespected. Hutchinson and Jackson (2015) found that nurses targeted by this type of surveillance felt exposed and vulnerable in the workplace. In this way, those who did not follow the constituted rules of the organization where are singled out and monitored by the rest of the group.  Surveillance undermines optimal care. In a critique of what could be understood as one form of surveillance and monitoring -- best practice guidelines, Holmes et al. (2008) further develop the concept of surveillance as a mechanism of control in nursing workplaces.  They propose that a powerful extension of surveillance is the practice of self-monitoring: that nurses continually monitor their practices based on policies and rules set by the organization, an approach to nursing practice that may be counter to their own beliefs about caring and safe practice.  The policies (and specifically, best practice guidelines) are used to keep themselves and other nurses’ practices in check. Feedback about adherence to these guidelines comes from managers, peers, and performance reports and this feedback tends to be internalized to regulate future behaviour (Holmes et al., 2008).  In this way, nurses start to self-monitor and stop questioning until the practice becomes indoctrinated with individual nurses and the group.  Critical analysis and strategic action by challenging or shaping discourse are lost as the nurse subconsciously feels compelled to follow protocol.  If best care is not being delivered as the organization deems, disciplinary measures are undertaken.  Holmes et al. (2008) raise concerns about the ways in which self-monitoring as a disciplinary technique has its roots in the politics of the organization whose goal and priorities become indoctrinated into the thinking and practice of individual nurses. 45 The authors of both articles reviewed here (Holmes et al., 2008; Hutchinson and Jackson, 2015) found that, in spite of organizational coercion, intimidation and influence, nurses can and do exercise resistance.  Nurses resist as a response to the unleashed control from the organization and its demands on their thinking and behaviour.  Foucault (1977) described resistance to be a response to certain power dynamics; inevitable and inherent to systems of power relations.  Nurses retain the ability to critically think, as seen in their work within very chaotic and stressful healthcare systems, and therefore cannot be entirely dominated.  However, organizations have institutionalized WPV so that unfortunately, nurses quickly learn that being outside of the set norms means being disciplined, excluded or alienated (St.-Pierre et al., 2008).  Analysis. These authors (Holmes et al., 2008; Hutchinson and Jackson, 2015; Hutchinson et al., 2006a) have demonstrated how surveillance and indoctrination have their roots in institutional power relations and have vital consequences for nursing work and potentially, for the health and safety of patients. Surveillance takes many forms, but in every case, it involves someone (a manager or a peer) scrutinizing nursing performance for adherence to formal or informal rules and directives. While standards of practice must exist, we need to think about how these standards are enforced in the workplace. Holmes et al. (2008) hold that the enforced enactment of guidelines and other forms of ‘rules’ leads undermines professionalism and critical thinking.  The indoctrination of WPV into the nursing culture has consequences for new graduates, in that they start to think that it is part of the job, and then succumb to the behaviour (Farrell, 2001).  In Hutchinson et al. (2006b), a nurse educator described that she felt part of her role was to forewarn nurses including new hires of the social realities in the work setting and educate on how to best assimilate not challenge them.  This acceptance of informal rules to abide to or else, 46 demonstrates the powerful indoctrination process happening in the profession.  New nursing graduates require guidance to ensure proper socialization into the profession (Kelly & Ahern, 2008; Pellico et al., 2009; Phillips et al., 2014). If practice environments are unsupportive, new NGs will endeavour to fit in the easiest way possible, meaning adopting and accepting the current practices of the unit rather than practicing their ideal conception of nursing. This is the practice environment into which new nurses enter. Having completed an education where a particular standard of practice has been taught, they are immediately under scrutiny. While much of what would be considered good nursing care is reflected in the rules and guidelines, it is the means by which they are enforced that may limit new graduates’ abilities to optimally learn, grow and practice in the workplace. It is in these settings that new nurses also learn that many rules are unwritten. Educating new NGs on the power imbalance that has been created between nurses in today’s healthcare organizations is needed.  Nurse educators should adopt curriculum that teaches against adapting and submitting to prevailing WPV behaviors, encouraging NGs to think about how they can play a part in transforming interpersonal relationships and change workplace atmosphere.  Summary In this chapter, an analysis of the literature chosen for the integrative review was outlined.  From the selected studies two themes emerged that point to significant ideas in explaining healthcare organizations’ impact on creating and sustaining WPV in their work environments.  This literature also illustrated that as a consequence of the unfair power relations in workplace settings, power disparities were not anticipated or manageable for NGs, causing disillusionment with the profession.  47 In the next chapter I explore the findings from this literature review and consider how these findings inform nurse educators as they seek to prepare NGs for the reality of WPV, and consider the responsibility of nurse leaders in shaping the conditions that will minimize violence in nurse workplaces.  48 CHAPTER 3 DISCUSSION OF FINDINGS AND IMPLICATIONS In this section I reflect on the findings from the integrative review and consider what they mean for nursing education, leadership and research. I propose some potential avenues for action that may contribute to the goal of creating equity and fairness for new nurses as they enter the nursing workforce. Nursing education programs have a professional responsibility to include topics related to WPV in curriculum so that NGs can be prepared for the realities of the workplace.  Preparing NGs for the challenges of the workplace is not enough. NGs need concrete tools and strategies so that they can contribute to shifting the organization’s power dynamics. We need nurses at all levels as well as other health professionals to recognize the influence of organizational structures on the everyday work experiences of NGs.  Educating for Practice when WPV is the Norm  Ignoring the issue of WPV in undergraduate programs is unfair to new nurses. Nurse educators have a responsibility to prepare new nurses for the realities of the workplace (Simons & Mawn, 2011). Most entry to practice nursing programs currently include some attention to power dynamics and the potential for workplace violence in health care organizations. The extent to which these are formally embedded in curricula varies. By addressing organizational power dynamics and by assisting new nurses to develop skills to deal with dynamics of WPV, NGs will be better prepared for the realities of nursing workplaces.  Hanson and McAllister (2017) propose that preparation for what they call ‘workplace adversity’ should begin early in nursing education programs. These authors define workplace adversity as “being unable to deliver patient care in the way that they were taught […], difficult transitions into practice, being socialized into negative workplace cultures and, being a target of workplace violence” (p. 90).  Specifically, they propose that assisting nurses to develop critical 49 self-awareness, an ability of being able to notice when their day-to-day work experiences conflict with their personal and professional values.  The authors also suggest providing guidance to assist nursing students to identify and name instances of workplace adversity.  Identifying the power relations that create these is of importance for educating NGs on WPV (Hanson & McAllister, 2017).  I believe that educating nurses about power in organizations based on a perspective of power as ubiquitous, dynamic and relational will offer useful tools that will support them as they enter the workforce. Methods of education could include; analysis of experiences in workplaces to make the power dynamics at play more visible, critically examining the different perspectives on power and the consequences of each, discussing how they might address instances of WPV, and assisting each student to develop their own definition of WPV.  I also believe that having conversations with students about how they perceive their role in the organization, specifically that power relations do not only work in one direction, and that they have the abilities to resist, question and hold power themselves.  As Hanson and McAllister (2017) point out, students who have experienced WPV but then were able to discuss the specifics of the situation were able to recognize the situation as a violent and dissect the context of the situation.  As one student commented after she had experienced a WPV situation, "This registered nurse is obviously entrenched in the ways as to how to treat nursing students because she was probably treated that same way herself"(p. 91).  In this regard, the student looked at the situation from a perspective that it is not about individual traits or faults, but rather the student analyzed the power dynamics in play within the organization and saw how they were shaping nursing relations.  It is at this point that nursing education can embark in having these complex discussions on power 50 dynamics, also examining where NGs can partake in transforming nursing interpersonal relationships. Addressing WPV in Nursing Curricula Teaching nursing students about violence has been a topic of some discussion in the literature (see for example, McGibbon & McPherson, 2006; Ross, 1995). A significant amount of this literature has focused on violence in domestic settings, and client violence against health care professionals.  We can draw on some of this literature in teaching students about WPV between peers – particularly what has already been learned about assisting students to learn about the role of power in various forms of violence situations.   Preparing students for the realities of WPV begins with supporting them to identify and describe power dynamics in everyday situations, and particularly, to be able to identify how various structural mechanisms shape power relations. An ability to analyze power dynamics has relevance to several other subject areas of nursing curricula including nurse-client relationships, nurse professionalism, and the social determinants of health. Embedding a consistent view of power and its relation to health and well-being throughout the curriculum would provide a foundation for prospective nurses, giving them tools to begin critically analyzing origins of violence in their workplaces, and how to develop strategies to deal with it.  The perspective on power that is embedded in the curriculum is important. If power relations are continued to be taken-for-granted in the nursing profession, methods to assist new nurses to deal with WPV (especially in its subtler forms) are largely limited to individual stress management and interpersonal conflict resolution. If we understand WPV as a function of complex power relations, then nursing students could learn to look not just at the interpersonal 51 level, but also to the ways that structural mechanisms of control have created and perpetuated the conditions for WPV.  Various authors have introduced strategies to assist new nurses to deal with what are described as ‘incivilities’ or ‘adverse events’. These include using problem based learning approaches (Clark, Ahten & Macy, 2013), role playing (Curtis, Bowen & Reid, 2007), cognitive rehearsal (Sanner-Stiehr & Ward-Smith, 2015, 2017), and narrative strategies (Hanson & McAllister, 2017).  All these strategies may provide valuable critical thinking tools for new graduates as they analyze the challenges they face and are able to develop concrete plans for action.  In providing these types of learning avenues, nurse educators can possibly create nonthreatening environments for prospective nurses to practice their responses to and critique strategies for WPV interactions that they may encounter in workplace settings.  However, it should be noted that the effectiveness of any approach will depend on the view of violence (and its relation to power) that is embedded in the teaching (Evans, 2017).  Preparing NGs through education to demand respect and challenge institutionalized WPV pervasiveness is a strategy that can help build their confidence when dealing with abusive behaviours.  Addressing WPV in nursing education has significance to the future of the nursing profession as it may promise to help in the initiation of creating healthy workplace environments. Shifting the Culture of Practice Assisting NGs to develop skills that allow them to shift organizational cultures is an essential step for change.  However, this approach alone may not significantly influence organizational dynamics.  If the goal of eliminating WPV is to be taken seriously, leaders at various levels of health care organizations have a significant role to play in making these 52 behaviours visible and shifting the power dynamics within the organization so all forms of WPV are no longer taken for granted.   Within the complex relations of power organizational contexts, the historical trend has moved from blaming the victim (in this case nurses) for actions that result in forms of WPV and moving towards taking a critical perspective to the organization’s role and influence in endorsing these types of power dynamics in their work environments (Holmes et al., 2008; Hutchinson & Jackson, 2015; Hutchinson et al., 2006a, 2006b, 2010; St-Pierre & Holmes, 2008).  The literature explored in this SPAR integrative review has identified organizational factors that precipitate and perpetuate bullying, such as; workplace environment, misuse of organizational procedures, standardization and overlooking WPV, and processes and informal subgroup alliances who help maintain the status quo.  As a result, this SPAR paper demonstrates consistencies in the literature regarding how WPV has become entrenched into nursing unit culture.  Specifically drawing on the literature analyzed in this SPAR paper, I have demonstrated that WPV can become institutionalized within the organization and therefore the cycle of violence continues to occur as it is viewed as normal part of the unit culture (Holmes et al., 2008; Hutchinson & Jackson, 2015; Hutchinson et al., 2006a, 2006b; St-Pierre & Holmes, 2008). The question remains then, by what means can nursing leaders, nursing educators, nurses and nursing students tackle WPV at the institution level? Perhaps specifically the power dynamics in the organization need to be confronted, so that established WPV practices are brought out in the open and challenged as being the norm.  Hutchinson et al. (2006b) suggest that through implementation of open disclosure policies, reconciliation and resolutions can be attempted to be made possible. The authors believe that redesign of the organizational structure is in order so that the ethics of public sector practices are made more accountable.   53 I believe as a registered nurse and educator not enough accountability has been assigned to the organizations and their structures that have created and sustained power disparities amongst nurses.   Asking organizations to look more intently at how their characteristics, such as policies and procedures, error reporting mechanisms, interpersonal relations amongst staff may be influencing WPV in the work environment is essential to instigating change.  Focusing more on these organizational characteristics offers possibility to pushing the focus even farther from considering WPV as an individual problem and placing more emphasis on organizational work processes.  Hutchinson et al. (2010) propose that changing to a more democratic work environment even a participatory model where socially constructed constitution of rules is thoroughly made visible, open to review and interpretation, can draw attention to existing power dynamics that support WPV.  Even though at this time there is not any concrete method about how to implicate organizations in their role of perpetuating WPV, identification of WPV as a systematic, planned, legitimized organizational behaviour allows more opportunities to widen the lens on how to best approach managing it. New Avenues for Research Overall, the findings of this integrative review have implications for nurses, nurse education and for the organizations that employ nurses. The findings highlight the need to prepare NGs for the possibility of WPV, including assisting them to develop strategies for responding to and challenging WPV. In this way, the responsibility for ending WPV must be a shared endeavour.  The literature used in this SPAR paper consistently portrayed NGs’ perceptions of WPV encounters. The review drew attention to the fact that NGs were unprepared for adverse features of the environment, such as emerging with recurrent themes of not 54 anticipating a lack of support or mistreatment from colleagues and institutional structures that perpetuate WPV.   As mentioned earlier, research addressing NGs experiences of WPV is scarce and of the literature on the topic available, very few articles take a critical perspective. Further research exploring the question of this SPAR that use larger sample sizes, and different research sites is recommended to support greater understanding of NGs preparation for WPV and mitigation of its’ effects.  More work is needed in studying interactions between individual relations and the organizational work systems they are a part of.  Analysis of these interactions could be key for creating preventative initiatives for WPV.   Limitations In searching for relevant literature for this SPAR paper, limited research was found on the proposed research questions.  Compounding the issue of a gap in this topic, most of the found research was Australian based.  It should be noted though that this limitation provides opportunity to identify this gap in the literature and demonstrate the need for further research.  As is evident from the research reviewed, there is basis that NGs experience difficulty when transitioning into the current power dynamics of health care environments. We need research conducted within Canada and British Columbia that will provide a more nuanced understanding of NGs’ experiences in this country.  The findings of this integrative review may be limited by the scope of my literature search. I focused mostly on literature published in the last ten years with the exception of a couple of articles.  Although this review led me into some literature from earlier years, especially the earlier work of Hutchinson and colleagues, a more systematic review of nursing literature from earlier years may yield some interesting results that could further this SPAR paper’s 55 analysis.  Finally, in this integrative review, I included articles addressing WPV from a critical perspective. This reflects a particular commitment to certain values and perspectives that not everyone will share.  These limitations strengthen the argument for the need of more research on the readiness NGs need to possess in addressing actual and potential WPV in their work environments.   Summary This chapter presented the findings from the literature review by addressing the key concepts gleaned from the research. The findings discussed in this chapter reinforce the implications and interrelatedness of the power dynamics that effect the practice environment for NGs.  Given the nursing profession’s role in creating environments that support professional practice, these results further suggest that more work is needed in education, research and the practice units in order to help make changes at the organizational level, as it will be a critical component for NG retention. The final chapter will present the conclusion and recommendations for this work moving forward.    56 CHAPTER 4 CONCLUSION AND RECOMMENDATIONS This integrative review has illuminated several key findings, which are important to consider in the advancement of research addressing NGs readiness for recognizing and managing WPV.  The review also highlights the possibilities of the organization’s role in creating and sustaining practice environments that foster power inequalities amongst nurses.  In this chapter, I summarize the findings and provide recommendations for the next steps in fostering healthier practice environments for the NGs.  Perceptions of Not Feeling Prepared Consistent throughout this integrative review is the theme in the literature that NGs were unaware of the power dynamics they encountered on entrance to the profession.  In three of the eight studies in this integrative review, NGs admitted to not being unprepared for important aspects of socialization process, specifically the lack of support, lack of respect and incivility (Phillips et al., 2014; Kelly & Ahern, 2008; Pellico et al., 2009).  NGs are at risk of having insufficient experience to be able to challenge WPV practices that are entrenched within the organization’s power dynamics.  The findings of this SPAR paper depict the consequences for NGs when WPV is normalization into the nursing culture.  During their transition period of entering into the profession, if they are not well supported or nurtured, NGs may come to understand current power structures in organizations as the norm in health care workplaces (Kelly & Ahern, 2008; Pellico et al., 2009; Phillips et al., 2014). Institutional Contributions to WPV  Another theme that emerged related to ways that organizational structures generate work environments that promote WPV behaviour.  Six of the eight articles chosen for this integrative review demonstrated various mechanisms that organizations rely upon to encourage nurses’ 57 obedience and compliance (Holmes et al., 2008; Hutchinson & Jackson, 2015; Hutchinson et al., 2006a, 2006b, 2010; St-Pierre & Holmes, 2008). Nurses are constantly being watched, either by patients, families, nursing supervisors, nursing’s professional regulatory body and even co-workers (St-Pierre & Holmes, 2008).  The constant monitoring sets up a work environment in which people tend to be quick to use judgement or discipline so that  maintain order is maintained (St-Pierre et al., 2008).  Foucault’s perspective on power draws attention to the consequences of this surveillance for nurses constantly being influenced and monitored in their workplace. Power in an organization is maintained by its workers adhering to the work environment norms; if there is a deviation from these norms, the individual is reprimanded through organizational disciplinary actions and peer judgement. Using Foucault’s perspective on power brings attention to the impact of nurses constantly being monitored in their workplace.  This can be characterized by changeable and unpredictable supervision, an atmosphere where the work and dignity of employees is undervalued, and less support is available even though more demanding work is accruing in the system (Holmes et al., 2008; Hutchinson & Jackson, 2015; Hutchinson et al., 2006a, 2006b, 2010; St‐Pierre & Holmes, 2008).  Implications and Recommendations for change Based on the literature explored in this SPAR, the ability of new nurses to do their jobs can be influenced by the organizational culture of their work environment (Holmes et al., 2008; Hutchinson & Jackson, 2015; Hutchinson et al., 2006a, 2006b, 2010; St‐Pierre & Holmes, 2008). Nursing graduates need to be given the chance to have proper role models and learning environments so they can apply their newly acquired clinical skills effectively, thus building upon their professional practice.  If there are not appropriate role models or learning environments for NGs, they can become more at risk of internalizing the bureaucratic values of 58 the organization as they socialize into their new professional roles (Kelly & Ahern, 2008; Pellico et al., 2009; Phillips et al., 2014). Attempting then to understand what happens among nurses in the nursing work environment in regard to organizational power dynamics has the potential to foster a more cohesive workplace.   Education and Support  NGs need to be taught and reminded about the power and influence they have within their own work environments, reinforcing their abilities to critically question and analyze entrenched coercive organizational work processes.  It is imperative, therefore, to implement educational strategies that promote knowledge and understanding of WPV and strategies for prevention before NGs enter their workplace settings.  Embedding topics of power and violence into nursing curriculum will help bring attention to complexities WPV.  Visiting these issues with prospective nurses in nursing curricula can help them develop attitudes and skill to challenge and confront current healthcare organizations’ ingrained ideologies.  Careful attention therefore needs to be given in current nursing education to implementing effective strategies that engage students and newly registered nurses to confront, defuse, and resist adopting WPV behaviours in their own professional nursing practice.  Nursing educators have a responsibility and an opportunity to interrupt the cycle of WPV through coaching and cultivating NGs on ways to help create respectful workplace environments.  Additional research evaluating NG readiness for WPV would be beneficial so that an awareness can be created that would help NGs hold nurses, nurse leaders and organizations accountable for their workplace behaviours.  Exposing nurses and new NGs to critically reflect on different views of power may also be helpful, educating that power can be held or refuted by anyone and that it is relational in nature not necessarily restrictive (Foucault, 1977). 59 Revision of Organization Structures Before the nursing profession has any chance of changing the incidence of WPV, a revision needs to occur at the level of the organization’s structure.  Stepping away from using the individual employee as the reason for bullying and incivility behaviours and focusing rather on organizational work processes is a productive place to start.  Reform can also be a possibility when looking more constructively at workplace practices and how they may be restrictive to producing healthy work settings as well as legitimately promoting systemic violence (Hutchinson & Jackson, 2015; Hutchinson et al., 2006a, 2006b, 2010).  Taking a step back and analyzing these organizational characteristics may allow for consideration of more inclusive practices in the workplace setting.  This may include; creating a workplace environment that values differing of opinions, implementation of mechanisms that endorse shared participation and ridding of processes or policies that do not encourage positive morale in the organization community.  Hutchinson et al. (2006b) also suggests organizations with less of a hierarchical structure can promote involvement and interaction with less emphasis on defining roles.  Changes in organization structure and systems can offer effective solutions in transforming the power dynamics of the nursing profession. Summary What does this mean for nurses? Foucault’s perspective on power that has been used as a theoretical perspective in this SPAR paper, brings understandings as to why violent behaviours in nursing workplaces exist, offering possible explanations for domination and control. These insights open new avenues for change.  Moving away from using the explanation that WPV is due to the individual being a victim or powerless or marginalized, a Foucauldian view offers nurses the idea that they own the ability to challenge the discourse on power dynamics in the 60 workplace in such ways that they can choose the way they react to and perpetuate workplace violence (Foucault, 1977).   Conclusion The nursing shortage is happening and worsening, supportive work environments for new NGs needs to become a priority for healthcare.  This SPAR study objectives were to examine NGs readiness for WPV and the institutional contributions that may add to the perpetuation of WPV.   In conducting the integrative literature review for the SPAR, it has become apparent the need for more research on the topic of NGs understanding of and readiness for actual and potential WPV.  This SPAR demonstrates the need for NGs to become more informed on the current power disparities occurring in the nursing profession.  Adding more emphasis on the power dynamics in organizations and their effects on perpetuating WPV to nursing curricula may aid NGs in formulating critical perspectives on power relations and empower them to question not succumb to them.  Further examining this topic can have a significant theoretical impact on future nurse education and has hopes of being expanded to include a metamorphism within the organizational structures of health care.     61 REFERENCES Andrews, D. R. (2013). Expectations of millennial nurse graduates transitioning into practice. Nursing Administration Quarterly, 37(2), 152-159. doi:10.1097/NAQ 0b013e3182869d9f  Bentley, T. A., Catley, B., Forsyth, D., & Tappin, D. (2014). Understanding workplace violence: The value of a systems perspective. 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