A Meta-Synthesis of Qualitative Evidence Describing Nurse Leaders' Experience of Upward Violence

Purpose: The increasing incidence of negative workplace behavior among nurses has received significant attention over decades, but only modest attention has been given to vertical violence directed upwards at a nurse in a position of authority (Branch, Ramsay & Barker, 2006). The upwards direction for vertical violence and bullying first appeared in the literature towards the end of the last decade. Violence directed to a person in authority may include incivility, passive aggressive behavior, rudeness, socially ostracizing, bullying, mobbing, threats or physical violence. It has been suggested that upwards bullying may be more difficult to detect due to it presenting (at least initially) in subtle ways, such as gossiping and criticism. Researchers have suggested that upwards violence may be an impetus for a hostile or toxic work environment and contribute to a loss of effective management, although the direction of causality may also be the reverse. In some instances, leadership credibility is totally destroyed, resulting in devastating personal and professional consequences for the nurse leader.

In an unpublished scoping review that we conducted to provide a detailed description of upwards violence and to identify its antecedents and outcomes, we found that leaders were reluctant to admit they were bullied by subordinates, perhaps because they felt they should be able to manage their subordinates’ behavior. We also found that while upwards violence typically begins with incivility, it may spiral to more threatening, aggressive, retaliatory actions against the person in authority. Antecedents of the violence included characteristics of the perpetrator and/or the recipient of the violence, and of the work context.

Upwards violence is an international issue and while this issue occurs in different disciplines, much of the discussion and research on this phenomenon in the literature has been in nursing. In resent years there has been a growth of research on upwards violence, and therefore it is timely to conduct a meta-synthesis on the experience of upwards violence in nursing. Findings derived from the synthesis of qualitative research are increasingly recognized as important “to inform questions of practice and policy in their own right” (Munn, Porritt, Lockwood, Aromataris & Pearson, 2014, p. 108).

Methods: A qualitative, systematic review methodology was used that synthesizes what is known about nurse leaders’ experience of upwards violence We used the Joanna Briggs systematic review methodology as described in Joanna Briggs Institute Reviewers’ Manual (Aromataris & Munn, eds, 2017)) Specifically, the review addresses the question: What is nurse leaders’ experience of upwards violence in nursing workplaces? The participants included in this review are nurse leaders who say they have experienced violence from persons they supervise. Studies included in the review are those published from the year 2000 onwards, and include studies using any type of qualitative methodology as long as the publication includes direct quotations from the nurse leaders about their experience of violence.

Results: A detailed description of the search strategy and the procedure for selecting studies is described, along with how we assured that only high quality qualitative studies were included in the review. The data extraction tool entitled JBI Qualitative Data Extraction Tool is discussed along with examples of extracted data, and the flow between data extracted and the final synthesis is shown to illustrate the JBI meta-aggregation approach to data synthesis. The synthesized themes are discussed. Using the ConQual (Munn et al., 2014) approach to establish confidence in the synthesis, the strength of the meta-synthesis results is shown.

Conclusion: This meta-synthesis strengthens what is known about nurse leaders' experience of upwards bullying. Upwards violence demoralizes nurse leaders and threatens future generations of nurses from seeking roles with authority and therefore, the findings from this meta-synthesis on nurse leaders' experience of upwards violence are of great importance for nurses in leadership positions and for the nursing profession. Implications for nursing practice and for future research are discussed.