University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA COMPARATIVE STUDY OF DISRUPTIVE BEHAVIORS AMONG NURSES IN PUBLIC AND PRIVATE HEALTHCARE INSTITUTIONS IN THE GREATER ACCRA REGION, GHANA LAWRENCIA AGGREY-BLUWEY DEPARTMENT OF PUBLIC ADMINISTRATION AND HEALTH SERVICES MANAGEMENT JULY, 2017 UNIVERSITY OF GHANA COLLEGE OF HUMANITIES University of Ghana http://ugspace.ug.edu.gh COMPARATIVE STUDY OF DISRUPTIVE BEHAVIORS AMONG NURSES IN PUBLIC AND PRIVATE HEALTHCARE INSTITUTIONS IN THE GREATER ACCRA REGION, GHANA BY LAWRENCIA AGGREY-BLUWEY (10273621) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL HEALTH SERVICES MANAGEMENT DEGREE DEPARTMENT OF PUBLIC ADMINISTRATION AND HEALTH SERVICES MANAGEMENT JULY, 2017 ii University of Ghana http://ugspace.ug.edu.gh DECLARATION I certify that this thesis has not already been submitted for any degree and is not being submitted as part of candidature for any other degree. I also certify that the thesis is a product of my work produced from research undertaken under supervision, and any help that I have received in preparing this thesis; and all sources used, have been duly acknowledged in this thesis. ……………………………… …………………………. Lawrencia Aggrey-Bluwey Date (10273621) iii University of Ghana http://ugspace.ug.edu.gh CERTIFICATION I hereby certify that this thesis was supervised in accordance with the procedures laid down by the University. ………………………………………….. ……………………………… Dr Patience Aseweh Abor Date iv University of Ghana http://ugspace.ug.edu.gh DEDICATION The work is dedicated to my parents, Dr and Mrs Francis Aggrey-Bluwey, for their unflinching support towards my educational goals. v University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS This thesis owes its success to several individuals and entities, who assisted me in diverse ways in the course of this research. First, I would like to thank the Almighty God for His abundant grace and favor bestowed on me throughout my education. Next, I would like to thank the University of Ghana Business School, specifically the Department of Public Administration and Health Services Management, for granting me the opportunity to pursue my MPhil degree. My sincere gratitude goes to my supervisor, Dr Patience Aseweh Abor for her immense support and guidance throughout the course of this study. I would like to express my earnest gratitude to my parents, Dr and Mrs Francis Aggrey Bluwey for their immense support through the tough times in my education. My sincere appreciation goes to DCOP/Dr Ebenezer Ewusi-Emmim for his support, technical advice and comments. To all the lecturers and staff of the University of Ghana Business School, I say a big thank you for your time and support offered me. I owe a huge debt of gratitude to the numerous authors whose works were consulted and whom I have duly acknowledged at the references section. I wish to say a special thank you to my colleagues in the Mphil Health Services Management (2017) class and all my friends, for their help and acts of kindness during the hard times. Finally, I would want to express my profound gratitude to the Management and staff of Achimota Hospital, Shai- Osudoku District Hospital, Medifem Hospital & Fertility Center, FOCOS Hospital, Empat- Claiquo Hospital and Dar-Bem Medical Center, especially the nurses who participated in this study. vi University of Ghana http://ugspace.ug.edu.gh Table of Contents Content Page DECLARATION ............................................................................................................... iii CERTIFICATION ............................................................................................................. iv DEDICATION .................................................................................................................... v ACKNOWLEDGEMENTS ............................................................................................... vi ABSTRACT ...................................................................................................................... xv CHAPTER ONE ............................................................................................................... 1 1.0 INTRODUCTION ........................................................................................................ 1 1.1 Background to the Study ........................................................................................... 1 1.2 Problem statement ................................................................................................ 3 1.3 Purpose of the study ............................................................................................. 6 1.4 Objectives ............................................................................................................. 7 1.5 Hypothesis ........................................................................................................... 7 1.6 Research questions ............................................................................................... 7 1.7 Significance of the study ..................................................................................... 8 1.8 Study Area: Greater Accra Region....................................................................... 8 1.9 Limitations of the study........................................................................................ 9 1.10 Delimitations of the study .................................................................................. 10 1.11 Operational definitions of key terms ................................................................. 10 vii University of Ghana http://ugspace.ug.edu.gh 1.12 Organization of the study ................................................................................... 11 CHAPTER TWO ............................................................................................................ 13 2.0 LITERATURE REVIEW ........................................................................................... 13 2.1 Introduction ....................................................................................................... 13 2.2 Review of empirical literature ................................................................................. 13 2.3 Public versus Private healthcare systems ................................................................ 14 2.4 The Healthcare system in Ghana ............................................................................. 15 2.5 The nurse-patient relationship ................................................................................. 17 2.6 Disruptive behaviors among nurses in healthcare ................................................... 22 2.7 Forms of disruptive nurse behavior ......................................................................... 23 2.8 Causes of disruptive nurse behaviors ...................................................................... 25 2.8.1 Environmental factors ....................................................................................... 26 2.8.2 Personal factors................................................................................................. 28 2.8.3 Behavioral factors ............................................................................................. 30 2.9 Effects of disruptive nurse behavior........................................................................ 31 2.10 Remedying disruptive behaviors among nurses in healthcare organizations ..... 33 2.11 Educational qualifications and behavior patterns of nurses .................................. 37 2.12 Theoretical and conceptual frameworks for the study ....................................... 38 2.13 The Social Cognitive Theory; Albert Bandura, (1986) ......................................... 39 2.14 Reciprocal determinism applied to the study ........................................................ 43 viii University of Ghana http://ugspace.ug.edu.gh 2.15 Chapter summary .................................................................................................. 44 CHAPTER THREE ........................................................................................................ 46 3.0 METHODOLOGY ..................................................................................................... 46 3.1 Introduction ........................................................................................................ 46 3.2 Identification of target healthcare institutions .................................................... 46 3.3 Research design .................................................................................................. 47 3.4 Population of the study ....................................................................................... 48 3.5 Sample size ......................................................................................................... 50 3.6 Sampling technique ............................................................................................ 50 3.7 Data collection instrument ................................................................................. 50 3.8 Ensuring validity and reliability ......................................................................... 51 3.9 Identification of behavior patterns ......................................................................... 51 3.10 Statistical analysis .............................................................................................. 51 3.11 Ethical consideration ............................................................................................. 52 3.12 Chapter summary .................................................................................................. 52 CHAPTER FOUR ........................................................................................................... 53 4.0 PRESENTATION OF RESULTS .............................................................................. 53 4.1 Introduction ............................................................................................................. 53 4.2 Presentation and analysis of findings ...................................................................... 53 4.3 Demographic characteristics of nurses .................................................................... 54 ix University of Ghana http://ugspace.ug.edu.gh 4.4 Identification of disruptive behaviors among professional nurses in the private and public healthcare institutions in the Greater Accra Region, Ghana. ............................. 64 4.5 Comparison of disruptive behaviors among nurses in the private and public healthcare institutions in the Greater Accra Region, Ghana. ........................................ 71 4.6 Relationship between educational qualification of nurses and disruptive behaviour patterns .......................................................................................................................... 75 4.7 Testing of hypothesis .............................................................................................. 78 4.8 Chapter summary .................................................................................................... 89 CHAPTER FIVE ............................................................................................................ 91 5.0 DISCUSSION OF FINDINGS ................................................................................... 91 5.1 Introduction ............................................................................................................. 91 5.2 Disruptive behaviors exhibited by professional nurses in private and public healthcare institutions in the Greater Accra Region of Ghana ...................................... 91 5.3 Comparison of disruptive behaviors exhibited by professional nurses in private and public healthcare institutions in the Greater Accra Region of Ghana ........................... 96 5.4 Hypothesis testing ................................................................................................. 105 5.5 Relationship(s) between educational qualifications of nurses and their behavior patterns ........................................................................................................................ 106 5.6 Chapter summary .................................................................................................. 110 CHAPTER SIX ............................................................................................................. 111 6.0 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ............................ 111 x University of Ghana http://ugspace.ug.edu.gh 6.1 Introduction ........................................................................................................... 111 6.2 Summary of the study ........................................................................................... 111 6.3 Conclusions ........................................................................................................... 113 6.4 Recommendations ................................................................................................. 117 6.5 Suggestions for future research ............................................................................. 119 APPENDICES ............................................................................................................... 129 Appendix A: Introductory letter to identified healthcare institutions ......................... 129 Appendix B: Research questionnaire .......................................................................... 130 Appendix C: Hypothesis test summary for Mann-Whitney U test ............................. 134 xi University of Ghana http://ugspace.ug.edu.gh List of Tables Table Page Table 3.1 Accessible population of the study…………………………...…………..49 Table 4.1 Gender distribution of nurses in private healthcare institutions..………….54 Table 4.2 Gender distribution of nurses in public healthcare institutions……………54 Table 4.3 Age distribution of nurses in private healthcare institutions………….…..55 Table 4.4 Age distribution of nurses in public healthcare institutions………….……56 Table 4.5 Qualification distribution of nurses in private healthcare institutions….....57 Table 4.6 Number of years of practice in the private sector……………………..…..58 Table 4.7 Number of years of practice in the public sector……………….….….…..58 Table 4.8 Number of promotions in the private sector……………………….….…..59 Table 4.9 Number of promotions in the public sector……………………….….……60 Table 4.10 Previous hospitals that nurses in the private sector have worked in..…….61 Table 4.11Previous hospitals that nurses in the public sector have worked in…..…...61 Table 4.12 Behavior patterns of nurses in private healthcare institutions……………65 Table 4.13 Disruptive behaviors exhibited by professional nurses in the private healthcare institutions in the Greater Accra Region, Ghana……………………..………….......67 Table 4.14 Behavior patterns of nurses in public healthcare institutions……..…….68 xii University of Ghana http://ugspace.ug.edu.gh Table 4.15 Disruptive Behaviors among professional nurses in the public healthcare institutions in the Greater Accra Region, Ghana………………………………..…….70 Table 4.16 Comparison of disruptive behavior among nurses in private and public healthcare institutions………………………….…………….………………………..71 Table 4.17 Frequency of disruptive behaviors among nurses in private and public healthcare institutions………………………………………….….……………..……73 Table 4.18 Most disruptive healthcare sector……………………………………...….74 Table 4.19 Relationship between educational qualification of nurses and their behavior patterns…………………………………….……………………………..……………76 xiii University of Ghana http://ugspace.ug.edu.gh List of Figures Figure Page Figure 2.1 Model of Reciprocal Determinism ………………………………………40 Figure 2.2 Conceptual framework ……………..………………………………..…...42 Figure 4.1 Category of nurses in the private sector..……………………………..…..62 Figure 4.2 Category of nurses in public sector ………………………………………63 xiv University of Ghana http://ugspace.ug.edu.gh ABSTRACT Nurses are the single group of healthcare professionals who are in closest proximity to patient care and as such, their behavior patterns greatly affect patient health outcomes. It is perceived that nurses in public healthcare institutions behave more disruptively, as compared to nurses in private healthcare institutions, who are perceived to be assertive. This study was aimed at comparing disruptive behaviors among nurses in private and public healthcare institutions in the Greater Accra Region of Ghana. Using a Cross- Sectional Survey approach, a total of 210 nurses were randomly sampled from six (two public and four private hospitals) purposively identified healthcare institutions. A total of twenty-eight behavior patterns were incorporated into a 36 item close ended questionnaire for data collection. The study revealed the presence of 23(82.14%) of the disruptive behaviors among private sector nurses, with public sector nurses exhibiting 22(78.57%) of the disruptive behavior patterns. Further tests revealed that irrespective of the fact that nurses are largely disruptive, nurses in private healthcare institutions are relatively more disruptive (85%), contrary to the general perception. The study revealed a relationship between educational qualification of nurses and all the 28 behavior patterns which were examined. Further, a positive relationship was identified between educational qualification and majority (78.57%) of the behavior patterns. In order to help curb the menace or disruptive behaviors while promoting assertiveness among nurses, the study recommended including disruptive behavior lessons in the curricula for nursing education, continuous professional development at all levels of nursing practice, prioritizing nurse behavior by health managers, instituting awards, coaching and mentorship schemes and better regulation of private hospitals. xv University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 INTRODUCTION 1.1 Background to the Study Organizations are found in all sectors of society, and are very crucial to human existence. Bittner (1965) refers to an organization as an established association of individuals or groups of individuals engaged in resolute activities ultimately directed towards the achievement of set objectives. Organizational behavior in a broader perspective has been said to be a study discipline that seeks to explore the various dynamics of individual and group behavior within an organization (Robbins, 2001). The healthcare sector exists as an organization to cater for the health needs of the people. Due to the critical nature of healthcare organizations, organizational behavior in healthcare is a field which deserves much attention. This is because the behavior patterns of health workers, especially nurses, have direct bearings on patient welfare (Ford, 2009). The study of organizations and organizational behavior have received immense attention from sociologists and scholars from other disciplines alike, resulting in the development of quite an array of theories and concepts in in the field of organizational behavior in recent times (Moore et al., 2012; De Dreu & Nauta, 2009; Ivanko, 2013; Yousaf, 2015). However, same cannot be said about the application of organizational behavior concepts in the healthcare context (Borkowski, 2016). Within the healthcare setting, nurses as a group of individuals are very crucial to the existence of healthcare sector organizations. Nurses are key players in healthcare organizations and contribute immensely towards its success or failure (Canvanah, Fisher, University of Ghana http://ugspace.ug.edu.gh Francis, & Gapp, 2012). This is so because nurses are the largest group of healthcare providers, who are in closest proximity to healthcare delivery, and as such, their behavior patterns, especially when disruptive, could have negative effects on patients, other health workers, and the healthcare system as a whole. Kilkus (1993) indicates that in nursing, assertive behaviour among its practitioners is an instrumental element for successful practice within the profession. Kilkus also affirms that disruptive behavior among healthcare professionals is widely documented as a problem which is frequently encountered in various healthcare institutions. These behaviors are exhibited in forms such as emotional and verbal abuse, physical violence and bullying. Disruptive nurse behavior, according to Jericho et al. (2010), have a significantly negative effect on attributes such as communication, concentration and collaboration among healthcare professionals, as well as fostering negative workplace relationships. It is evident that the apparent behavior of a nurse is imperative to the success or failure of either a public or private healthcare system. As the assertive behaviors are encouraged to be maintained, disruptive behaviors, which are rather commonly exhibited by nurses, are discouraged to be remedied (Rosenstein & O'Daniel, 2008). The system of healthcare in Ghana is known to be dominated by two broad groups of institutions based on ownership: public and private. While one of the institutions can be described as ‘for profit’, the other is ‘not for profit’. The former is dominated by the private sector, and the ownership of the latter is the Government of Ghana (Ofosu-Kwarteng, 2012). Ghana continues to support the government partnership with the private health sector and duly recognizes its importance and potential (MOH, 2003). It is with this understanding that professional nurses are permitted to enlist and work in the private sector 2 University of Ghana http://ugspace.ug.edu.gh even though the public sector exists. Each of the types of healthcare institutions relies on the services of professional nurses of various grades. Leveck (1996) identified key factors that generally influence individual nursing behavior in nursing practice. These factors include, but are not limited to the environment, leadership style, stress within the hospital setting, and job satisfaction among nurses, group behavior, nurse retention and turnover. While the very behavior of a professional nurse may adversely or positively affect healthcare delivery in-terms of patients’ recovery and speed of medical interventions, it may also affect productivity and profitability (Borkowski, 2016). The behavior of professional nurses that may affect work negatively may be considered as disruptive behavior. 1.2 Problem statement Disruptive behaviors are existent in all kinds of organizations; however, the problem of disruptive behaviors seems especially prevalent in nursing (Jericho et al., 2010). The impact of such behaviors in the healthcare setting is highly significant because within the healthcare context, human lives are being dealt with, and as such, patient welfare and safety are at stake (Borkowski, 2016). In western countries, such behavior patterns have been reported to be exhibited by nurses in many forms including bullying, emotional abuse, negligence and physical abuse (Delucia, Palmieri, & Ott, 2009). In Ghana, public opinion has it that nurses are generally disruptive, however, empirical data regarding disruptive nurse behavior in the Ghanaian context remains unavailable (Ofosu-Kwarteng, 2012). Rosenstein & O'Daniel (2008) reported significant positive correlations between disruptive nurse behavior and medical errors, high staff turnover, medico-legal issues, complications 3 University of Ghana http://ugspace.ug.edu.gh in patient disease conditions and patient death. Further, Johnson (2009) has indicated that medical errors resulting from undesirable nurse behavior patterns are the case of death of an estimated 250,000 people per-anum in the United States alone, making it the third leading cause of death behind heart disease and cancer. However, because disruptive nurse and clinician behavior is never documented as the underlying cause of death for any mortality case, documentation regarding such behavior patterns is rarely available, thus, reducing public attention on the subject matter. These instances interfere with the ability of nurses to efficiently execute their duties, and eventually undermine patients’ confidence in the healthcare system. Nurses comprise by far the largest single group of health workers in the healthcare system (American Association of Colleges of Nursing, 2016), and as such, the sort of behavior exhibited by nurses affects every aspect of healthcare, both in the private and the public sector. This is because nurses spend a greater amount of time with their patients, as compared to other health professionals (Delucia, Palmieri, & Ott, 2009). When left unchecked, disruptive behaviors among nurses result in medical errors and injuries to staff and patients (Hader, 2008), complications in patients’ health problems (Borkowski, 2016), emergence of medico-legal issues (Berman-Kishony & Shvarts, 2015), and in some instances, death (Wood, 2012). Public perception has it that, nurses in private hospitals are better behaved as compared to their counterparts in public hospitals (Ojwang, Ogutu, &Matu, 2013). However, little empirical evidence exists to back this claim. It is thus important to study the differences in disruptive behavior among nurses in public and private healthcare institutions. 4 University of Ghana http://ugspace.ug.edu.gh Obuobi et al. (1999) identified that patients from various socio-economic groups, when given the option to choose, patronize private health care services over public healthcare services and this choice is generally due to the perception that nurses in private healthcare institutions are better behaved and are more receptive to patients, as compared to nurses in public healthcare institutions. Ofosu-Kwarteng (2012) documented some negative patient experiences in the public hospital setting, indicating disruptive behaviors among nurses in such hospitals. These include nurses being verbally abusive to patients, nurses neglecting and exhibiting harsh attitudes towards patients. Other behavior patterns which have been discovered include nurses discriminating among patients based on their perceived social status. Timmins & McCabe (2004) also reported that majority of health workers had observed disruptive behaviors among nurses in private healthcare institutions, while few had observed nurses in public healthcare institutions as being disruptive. Further, many of such behavior patterns were reported to have resulted in medical errors, while few ultimately resulted in death. In Ghana, data regarding disruptive behavior among nurses in private hospitals is however scanty. This could be as a result of hesitance on the part of private healthcare managers in providing researchers with such information. Educational qualification among nurses is an important factor when considering the behavior patterns of nurses. It is believed that as nurses rise through the ranks, they acquire additional education and training, thus, is safe to infer that senior nurses are more highly educated that junior nurses. Bullying, emotional abuse, and other forms of disruptive behaviors are found to be common as nurses transition from being trainees to professional nurses, and it continues as they climb the ladder (Gokenbach, 2012). Also, Farrell (1997) 5 University of Ghana http://ugspace.ug.edu.gh reported that the incidences of nurse to nurse disruptiveness are more often carried out by senior nurses against junior and newly licensed nurses. On the surface, it appears as though there is some form of relationship between educational qualification and disruptiveness among nurses; however, statistical testing regarding the nature of this presumed relationship is unavailable (Gokenbach, 2012). Borkowski (2016) reported that junior nurses, patients, and other junior members of the healthcare team are usually at the receiving end of disruptive behaviors which are exhibited by senior nurses. Farrell, (2001) further described disruptiveness, especially bullying, as a contagion which spreads through the nurse force. Nurses are believed to acquire disruptive behavior traits as they rise through the ranks in the profession, thus the phrase “Nurses feed on their young” (Bartunek, 2011). It is therefore important to establish nature of the relationship (if any), between educational qualification of nurses and disruptive behavior patterns, so as to find remedies to combat the phenomenon of disruptive nurse behaviors among nurses. The researcher also believes that it is important to identify the disruptive behavior patterns which are exhibited by nurses in the Greater Accra Region of Ghana and compare such behavior patterns in both healthcare sectors; public and private, in order to identify specific solutions to the phenomenon in each healthcare sector. 1.3 Purpose of the study This study was aimed at comparing disruptive organizational behaviors of professional nurses in public and private healthcare institutions in the Greater Accra region of Ghana. It sought to do so with the intention of suggesting ways by which the disparities in 6 University of Ghana http://ugspace.ug.edu.gh organizational behavior in private and public healthcare institutions can be remedied to ensure optimal productivity. 1.4 Objectives The general objective of this study is to compare the organizational behavior of professional nurses in public and private healthcare institutions. Specifically, the study seeks to: 1. Identify the disruptive behaviors of professional nurses in public and private healthcare institutions in the Greater Accra Region of Ghana. 2. Compare the disruptive behaviors of professional nurses in public and private healthcare institutions in the Greater Accra Region of Ghana. 3. Determine relationship(s) between educational qualification and disruptive behavior patterns of professional nurses in the private and public healthcare institutions in the Greater Accra Region of Ghana. 1.5 Hypothesis The working hypothesis of this study is that: 1. There is a significant difference disruptive behaviors of professional nurses in public and private healthcare institutions in the Greater Accra Region, Ghana 1.6 Research questions The questions this study seeks to answer are as follows: 1. What are the disruptive behaviors exhibited by nurses in public and private healthcare facilities in the Greater Accra Region, Ghana? 7 University of Ghana http://ugspace.ug.edu.gh 2. Is there a difference in disruptive behaviors exhibited by professional nurses in private and public healthcare institutions? 3. What is (are) the relationship(s) between educational qualification and disruptive behavior patterns of professional nurses in the private and public healthcare institutions in the Greater Accra Region of Ghana? 1.7 Significance of the study Findings from this study will inform professional practice of nurses in the healthcare industry. The study will provide healthcare practitioners with relevant information about how individual and group behaviors affect the healthcare institution. It will also inform healthcare managers on the nature of disruptive behaviors in their various healthcare institutions. The findings would further guide policy makers on how disruptive behaviors in public and private healthcare institutions could be remedied and assertive behavior upheld. The study is also expected to add to the existing knowledge on professional behavior of nurses in the healthcare sector and ways of rectifying disruptive behaviors of nurses. This study will therefore serve as a basis for future research on organizational behavior of professional nurses in the healthcare sector. 1.8 Study Area: Greater Accra Region The Greater Accra Region of Ghana is located in the southern part of Ghana. It is bordered to the north by the Eastern Region, to the east by Lake Volta, to the south by the Gulf of Guinea, and to the west by the Central region. The Greater Accra Region covers an area of 8 University of Ghana http://ugspace.ug.edu.gh 3,245 square kilometers, which translates to 1.4 per cent of the total land area of Ghana and is the administrative capital of the Republic of Ghana. The region consists of five districts. These include Tema, Accra, Dangbe West, Dangbe East, and Ga. The Tema district is the largest industrial center in Ghana, followed by the Accra district. The Accra district, which also happens to be the capital of Ghana, is the primary investment and commercial center in the Greater Accra Region (Ghana Statistical Service, 2004). Using a highly networked collection of publicly owned healthcare facilities, the Ministry of Health delivers health services within the Greater Accra Region. These facilities include health centers, clinics, polyclinics and hospitals. The Private sector also provides healthcare within the Greater Accra region using a mix of health workers such as doctors, pharmacists and chemical sellers, non-governmental organizations (NGOs); who constitute the formal practitioners; and the informal practitioners including traditional birth attendants and herbalists(MOH, 2003). 1.9 Limitations of the study A major limitation of the study was the inability to get an equal sample of respondents with the same professional nursing rank, same gender, equal age, and same specialization across the private and public healthcare systems. It is believed that each of these variables may put varying weights on the averages of responses from the public sector healthcare system as against those in the private sector healthcare systems. The study believes that the ideal situation should have been a sample with same professional nursing rank, equal gender composition, equal age, and same specialization across the private and public healthcare systems; as this may nullify all likely biases. 9 University of Ghana http://ugspace.ug.edu.gh 1.10 Delimitations of the study This study was carried out in the Greater Accra Region of Ghana. The results may therefore not be applicable to healthcare institutions in other regions of the country and elsewhere. Also, the various factors which contribute to disruptive behaviors among nurses in both private and public healthcare institutions could range from genetic, physical, professional and even social factors both within and outside the hospital setting (Longo, 2010). These factors would require further enquiry and as such, are considered to be outside the scope of this study. Due to this, such factors are not included in the objectives of the study, but are discussed briefly in the literature review. 1.11 Operational definitions of key terms 1. Healthcare Institutions: individual and publicly owned hospitals settings, whose primary purpose is to provide health related services to individuals within their catchment areas. 2. Organizational behavior: the study of human behavior within organizations 3. Behavior: how individuals act within an organization. Used interchangeably with organizational behavior 4. Assertive behavior: actions by health workers which are considered as being professionally correct, and which do not infringe on the rights of other people. 5. Disruptive behavior: actions by health workers which go contrary to the professionally acceptable codes of conduct. 10 University of Ghana http://ugspace.ug.edu.gh 6. Professional nurse: a person who has received some level of education in nursing and/ or midwifery, and is duly licensed by the Nursing and midwifery Council of Ghana. Used interchangeably with “nurse”. 7. Private Healthcare Institution: a health care facility owned by an individual, group of individuals or organization with the aim of profit making. 8. Public Healthcare Institution: a health care facility owned by government to serve the health needs of the people but not aimed at making profit. 1.12 Organization of the study This study is presented in six chapters. Chapter one, which is the Introduction chapter, contains background literature pertaining to the area of Organizational Behavior. It highlights some basic definitions of organizational behavior and its importance, particularly to the healthcare industry and with a focus on the phenomenon among nurses. Chapter one also contains the problem statement, the purpose of the study, its significance, the research objectives, hypotheses, research questions, the scope of the study and definition of certain key terminologies which are used in the study. Chapter two contains a review of relevant literature from journal articles, articles from websites and newspaper publications and also presents the Research Framework intended to guide the study. The Research Framework consists of a theory in the field of organizational behavior together with a conceptual framework based on the theory which were meant to guide the study. 11 University of Ghana http://ugspace.ug.edu.gh In chapter three, various techniques which were adopted in carrying out this study are outlined. The chapter comprises of the research design, population, sample and sampling technique, instrumentation, data collection techniques and data analysis. Chapter four presents the results from data analysis and the findings of the study. Chapter five presents a discussion of the results in relation to existing literature. In chapter six, conclusions and recommendations outlined by the researcher as per the results of the study are presented, and a comprehensive summary of the entire thesis is spelt out. 12 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Introduction Kleft (2014) has described nurses as the “single most important category of healthcare professionals”, and it is for this reason that disruptive nurse behavior negatively impacts the health and safety of nurses, patients, other members of the healthcare team, and the healthcare system as a whole. Disruptive behaviors among nurses have long existed, however, little has been done in the bid to curb such behaviors and in effect, promote assertive behaviors among nurses (Longo, 2010). Because disruptive behaviors among nurses have largely gone unchecked, they have gradually become accepted at a part of the healthcare system, and for this reason, urgent, context specific remedial measures are needed, in order to combat the menace (Longo, 2010). This chapter presents a review of relevant theoretical and empirical literature in the field of organizational behavior among nurses, specifically, disruptive nurse behavior. Concepts are further operationalized for the purposes of this study. 2.2 Review of empirical literature This section presents a critical review of empirical literature in the field of organizational behavior among nurses, with particular attention to disruptive nurse behavior. Empirical literature is reviewed under the following headings: public and private healthcare systems, the Ghanaian healthcare system, the nurse-patient relationship, forms of disruptive nurse behavior, causes of disruptive nurse behavior; environmental factors, personal factors, behavioral factors; effects of disruptive nurse behavior, remedying disruptive behavior among nurses, and educational qualifications and behavior patterns of nurses. 13 University of Ghana http://ugspace.ug.edu.gh 2.3 Public versus Private healthcare systems A healthcare system refers to the totality of organizations, professionals and services whose primary purpose is to encourage and restore optimal health. It refers to the organization of individuals, facilities, and resources (both financial and non-financial) which are used to provide health services in order to meet the health needs of a target population (World Health Organization, 2007). A healthcare system has a core responsibility of influencing the determinants of health, towards the promotion activities which are tailored towards improving health. A health system goes beyond a collection of government owned health facilities which deliver personal health services. Healthcare systems also include for example, parents caring for their sick children at home, individually owned healthcare facilities, programs which encourage behavior change, and providers of health insurance schemes (World Bank, 2007). Healthcare systems can largely be classified as public and private healthcare systems. It is important to review and compare the public and private healthcare systems in this context. This is because both sides of the healthcare system employ the services of nurses, and thus, nurse behavior affects patient care in both settings. The private healthcare system, also known as the “non-government “healthcare system consists of privately owned hospitals, health insurance companies, dental clinics, pharmacies, acupuncture centers, physiotherapist centers and care homes (Tateke, Woldie, & Ololo, 2013). The government does not finance these facilities. In this context, the private healthcare system may include for-profit healthcare organizations, charitable and non-profit healthcare organizations, as 14 University of Ghana http://ugspace.ug.edu.gh well as healthcare facilities owned by individuals and families. Financing of such services at such facilities is usually through individual out-of-pocket payments and private health insurance financing (Healthcare Domain, 2013). The private healthcare sector can be divided into private not for profit and private for profit institutions. The private for profit institutions are those which seek to make return on investments, whiles the private not for profit institutions seek to operate mostly as charitable organizations (Becker, 2014). The public system on the contrary, is run by the government and is paid for by taxes accrued by the State. It refers to a group of hospital systems, patient care services and public health programs which are funded and owned by the state, local or federal governments (Teasley, 2003). The government healthcare system as opposed to the private system is composed of hospitals which are solely run not for profit (Becker, 2014). People seeking healthcare may choose to patronize either a private or public health care facility for an array of reasons. These reasons range from the waiting times for specific treatments, particular treatment required, type of funding and cost of healthcare, and quality of care rendered (Healthcare Domain, 2013). The behavior of health workers in each facility may also be a determining factor, in the selection. 2.4 The Healthcare system in Ghana The health system in Ghana comprises of government, individual and traditional providers, civil society, community groups and other providers who fall under the category of non- governmental organizations (Bampoe, 2015). These providers however require 15 University of Ghana http://ugspace.ug.edu.gh collaboration with each other in order to have positive impact on health outcomes. Healthcare in Ghana is largely provided by the government under the Ministry of Health and the Ghana Health Service (Adinkrah, 2014). However, the private health sector plays a major role in the provision and financing of healthcare in the country (Loh, Ugarte-Gil, & Darko, 2012). Despite the fact that the main purpose of both healthcare systems is to provide optimal healthcare towards satisfying the health needs of the populations they serve, there are certain key differences between private and public health facilities in Ghana. Faimunissa & Arjumand, (2014) reported higher cost of services in the private healthcare system, better individualized care in the private healthcare system, longer waiting times in the public healthcare system and higher provider-patient ratios in public healthcare as some of the major differences in both health systems. According to Fierlbeck & Palley (2015), another significant difference between both health sectors is that the private health system has better and more modern equipment which result in better patient care. This is however not always the case because in recent times, some public health facilities in Ghana are now being furnished with ultramodern health care equipment, making patient care more effective and efficient. Generally, there is a perception that nurses in private healthcare institutions exhibit less disruptive organizational behavior as compared to their counterparts in the public sector (Ojwang, Ogutu, &Matu, 2013) and as such, the patient, if given the chance, will rather patronize a private healthcare facility as compared to a public one. However, little 16 University of Ghana http://ugspace.ug.edu.gh empirical evidence exists to back this claim. It is therefore imperative to study the differences in disruptive behaviors among nurses in both the private and public health sector, outline the effects of such behaviors of nurses on healthcare delivery in the private and public systems, so as to ultimately provide remedies for curtailing suboptimal organizational behavior in the healthcare system, towards improving nurse and patient outcomes. 2.5 The nurse-patient relationship The nurse-patient relationship is a therapeutic interaction between the nurse and the patient seeking healthcare, which is based on mutual trust, hope and sensitivity to the patient’s needs (Rivers, 2011). The Ontario College of Nurses (2006) and CRNBC (2016) have described the nurse-patient relationship as “the core of nursing practice”. It is a relationship which is aimed towards supporting the patient’s wellbeing. In this relationship, the duty of the nurse is to create and maintain rapport with the patient by using professional nursing skills together with a caring and empathetic attitude (Peterneij-Taylor & Yonge, 2003). The core purpose of this relationship is to improve patient’s health outcomes. Irrespective of the context, the length of stay in the hospital, and whether or not the nurse is the primary or secondary caregiver for the patient, the nurse-patient relationship has certain constant components. These components, according to the Ontario College of Nurses (2006), include but are not limited to trust, power, professional intimacy, empathy, and respect. It goes to say, that the behavior patterns exhibited by nurses within the confines of the 17 University of Ghana http://ugspace.ug.edu.gh therapeutic nurse-patient relationship is an embodiment of the ideal sort of behavior which is expected of nurses (CRNBC, 2016). Any deviation from this “ideal” is termed disruptive nurse behavior. Trust, is a critical value in the nurse-patient relationship. Within this context, trust is defined as the belief that a person’s good will be well taken care of (Liu, Wong, & Mok, 2006), or an attitude whereby one relies with confidence on someone or something, to have things done (Meize-Grochowski, 1984). According to Nizar (2013), trust is arguably the most important component of the nurse-patient relationship. This is because right from the moment the patient walks into a health facility, the patient depends on the nurse in the hopes of having positive health outcomes. Several factors need to exist before trust is gained in the nurse-patient relationship. First of all, the nurse needs to prove to the patient that he or she will be available whenever the need be and must communicate with the patient in a respectful manner (Liu, Wong, & Mok, 2006), the patient should be made to have a feeling of emotional and physical safety (Langley & Klopper, 2005), he or she should be made to feel at home and be given sufficient knowledge, as feasibly as possible, of their disease condition (Benkert & Tate, 2008). To develop trust in the nurse-patient relationship, it is important for the nurse to build a level of rapport with the patient and get to know him or her, in order for the patient to feel comfortable around the nurse. A study conducted by Benkert & Wickson (2009) to assess the relationship between mistrust and patient outcomes revealed that there is a positive relationship between trust and patient outcomes in the clinical setting. This finding is 18 University of Ghana http://ugspace.ug.edu.gh however contrary to findings from a study conducted by Burge (2009), which concluded that there is no significant relationship between patient trust of nurses, and the outcome of patients’ disease condition. Besides trust, power is another essential element of the nurse-patient relationship. Although the nurse may not realize it immediately, the nurse has more power than the patient in the nurse-patient relationship. Within this relationship, the patient is often the vulnerable party. This is because the nurse has more influence, is more knowledgeable and has certain specialized skills which give them an upper hand over the patient (CRNBC, 2016). Also, the nurse has more access to specialized information and has the ability to act as an advocate for the patients and their relatives. This power, when appropriately used by nurses enables the nurse to act in an appropriate manner towards meeting the patient’s needs and thus improving patient health outcomes (Burge, 2009). The day to day duties of every nurse require some level of intimacy with the patients. Activities such as bathing, feeding, and attending to the personal needs of the patient require that the nurse gets involved with the patient to a certain extent. This sort of intimacy, however, needs to be exhibited with a great deal of professionalism. Professional intimacy is described by Huebner, (2007) as “intimate exchanges between nurses, patients, and family members in which the nurse must balance the patient’s emotional and physical needs in a turbulent work environment”. It refers to a complex set of physical, emotional, psychological and spiritual attributes that create seemingly closeness between nurses and 19 University of Ghana http://ugspace.ug.edu.gh patients, while maintaining a great deal of professionalism (CRMN, 2011). Professional intimacy between nurses and patients is crucial towards ensuring patients’ health, wellbeing and recovery. It requires a great level of skill, strategy and experience on the part of the nurse, so as not to cross certain boundaries whiles being intimate with the patient. (Ontario College of Nurses, 2006). Clinical empathy is another behavioral trait which is essential in the delivery of nursing care by virtue of the nurse-patient relationship. Empathy, according to Gokenbach (2012), is the nurse’s willingness to share in the feelings of his/ her patients. Clinical empathy is a complex phenomenon and includes the ability of the nurse to understand the patient’s feelings, communicate that understanding, and act on that understanding to the patient’s advantage (Mercer & Reynolds, 2002). Empathy has been proven to enhance provider- patient relationships (Levinson & Gorawa-Bhat, 2000), improve patient satisfaction and compliance (Kim, Kaplowitz, &Johnston, 2004), result in better health outcomes and increase patient’s perception of quality of care (Mercer & Reynolds, 2002). Reynolds & Scott (2000) asserted that clinical empathy, to a greater extent, is lacking in the nursing profession. That is to say that nurses in both private and public healthcare institutions do not display an adequate level of empathy towards their patients. However, Mercer & Reynolds (2002) explained this assertion by positing that there is a growing patient workload on clinical practitioners. Thus the higher patient provider ratios serve as a constraint towards exhibiting empathy, on the part of nurses. 20 University of Ghana http://ugspace.ug.edu.gh The study conducted by Reynolds & Scott (2000), was however disproved by Fields et al. (2004) who revealed that nurses exhibit a great level of clinical empathy which benefits not only patients, but all other members of the healthcare team. Fields et al., (2004) conducted a cross-sectional survey to compare levels of clinical empathy among a sample of 56 professional nurses and 42 physicians in the Thomas Jefferson Hospital using the Jefferson Scale of Clinician Empathy. The study revealed a significantly higher level of clinical empathy among the professional nurses than physicians. This goes to say that nurses exhibit a higher level of clinical empathy towards patients. A comparative cross-sectional study was conducted by Tateke, Woldie, & Ololo, (2013) to measure the level of patients’ perception of healthcare provider empathy in private and public healthcare institutions. The study revealed a statistically significant difference in perceived provider empathy in public and private hospitals. This revelation projects the nature of behavior patterns of health workers and nurses for that matter in private and public hospitals. It goes to show that there is a significant difference in behavior of staff in private and public healthcare facilities. A systematic review conducted by Basu et al., (2012) to compare the behavior pattern of professionals in public and private healthcare systems in low and middle income countries revealed that health workers in the private healthcare sector were more hospitable and responded in a more timely manner to patient needs. The public healthcare sector on the other hand, tended to be less responsive to patient needs. In effect, it can be inferred that nurses in the private healthcare sector, in the context of this study, are more hospitable, 21 University of Ghana http://ugspace.ug.edu.gh respond in a timelier manner and are more responsive to patient needs, as compared to nurses in the public healthcare sector. 2.6 Disruptive behaviors among nurses in healthcare Disruptive behaviors refer to all those observable and unobservable events that are carried out by any member of the healthcare team that may threaten the performance healthcare professionals, and eventually undermine the wellbeing of the patient (Joint Commission, 2008). Disruptive behaviors among healthcare professionals have also been defined by the American Medical Association (2002) as personal conduct of a health worker; whether verbal or physical; which potentially or actually affects patient care in a negative manner. Harder (2008) has also described disruptive behaviors among nurses as an “occupational hazard” which has several clinical, legal and ethical implications for both patients and healthcare workers. Disruptive behaviors among nurses and other members of the health team exist in all aspects of the healthcare system. Such behaviors pose as a threat first of all to the culture of safety, retention of nursing staff, and ultimately to patient safety (International Society of Psychiatric Mental-Health Nurses, 2014). Even though disruptive behaviors have long been existent in the healthcare sector, they have received little attention, gone unchecked, and have subtly become acceptable as part of the system (Longo, 2010; Hader, 2008; U.S. Department of Health and Human Services, 2016). 22 University of Ghana http://ugspace.ug.edu.gh 2.7 Forms of disruptive nurse behavior There are many forms in which disruptive behaviors among nurses are exhibited. A few of these forms are enumerated below; a) Lateral violence: this refers to aggression between two or more nurses who are on the same level of the nursing hierarchy. These nurses may either be on the same rank and/or belong to the same specialty (Griffin, 2004). For example, aggression between two or more staff nurses or two or more Nursing Officers may constitute lateral violence b) Vertical violence: aggression between two or more nurses on different level of the nursing hierarchy. Such aggression is either directed upwards or downwards on the hierarchy (Stanely, 2010). For example, aggression between a Nurse in Charge of ward who happens to be a Senior Nursing Officer and an Enrolled Nurse. c) Incivility: this has been described by Clarke (2013) as “disregard and insolence for others causing an atmosphere of disrespect, stress and conflict”. Contrary to lateral and vertical violence, incivility among nurses may be directed towards other nurses, other members of the health team such as physicians, and/or patients. d) Bullying: Vessey et al. (2009) defined bullying as intimidation, abuse of offensive behavior that make the recipient feel embarrassed or threatened and ultimately undermine their self-confidence. e) Verbal abuse: Verbal abuse is defined by Ford (2009) as constant name calling and sarcastic comments which include calling a person derogatory names. 23 University of Ghana http://ugspace.ug.edu.gh f) Negligence: within the context of the nursing profession, American Medical Association (2002) defines negligence as failure of a nurse to execute patient care in a reasonable manner, resulting in avoidable patient injury g) Physical abuse: Deliberate acts which cause injury or trauma to another person Jericho et al. (2010). Many examples of disruptive behavior patterns which are exhibited by nurses have been outlined in literature. These behavior patterns range from outbursts of anger within the hospital setting, sexual harassments in the wards, backbiting, spreading rumors and attempting to blackmail other members of the professional nursing staff, nurses fighting with other nurses and screaming at each other, alcohol use whiles on duty, nurses bullying student nurses on clinical duties, humiliating subordinates and other members of the healthcare team, demeaning behavior, cracking of racial or ethnic jokes, refusal of nurses to work with other nurses, intimidating each other, passing degrading comments about other nurses, criticizing other health workers in front of patients or other health staff, and passing comments which weaken a patient's trust in other caregivers or the healthcare system (Borkowski, 2016). Others include backbiting and engaging in verbal exchanges, not completing patient care procedures before leaving the hospital and improper handing over, nurses demanding illegal fees from patients and pocketing hospital monies (Hader,2008; Rocker, 2008; Capitulo, 2009; Borkowski, 2016) 24 University of Ghana http://ugspace.ug.edu.gh According to a survey conducted by Hader (2008) victims of disruptive behavior in the healthcare setting include nurses, physicians, patients and patient relatives. Out of a sample size of nearly 1,400 registered nurses, nearly 80% reported witnessing a nursing colleague being subjected to violence in the work place and 50% reported having been victims of workplace violence themselves. Hader (2008) also revealed that nurses are subject to disruptive behavior mostly by patients (53.2% of the sample), followed by other nurses (51.9%). Heqney et al., (2003), Hesketh et al, (2003) and Rowe & Sherlock (2005) also asserted that disruptive behaviors among nurses are mostly reported as coming from their colleague nurses. It is therefore safe to conclude that more than half of the time, nurses are subjected to disruptive behaviors from their colleague nurses rather than patients and other members of the health team. 2.8 Causes of disruptive nurse behaviors An extensive review of literature has revealed a wide variety of causes of disruptive behavior among nurses. The first essential step in addressing disruptive behaviors among nurses is to first of all obtain a full understanding of the causes of disruptive behaviors in healthcare (Clarke, 2013). Weber (2004) has reported that disruptive behavior among nurses is a complex phenomenon, and that the factors which contribute to such behaviors operate on multiple levels. For the purposes of this study, literature regarding the causes of disruptive nurse behavior will be reviewed according to the concept of Reciprocal Determinism (Bandura, 1986). These include environmental factors, behavioral factors and personal factors of the individual nurse. 25 University of Ghana http://ugspace.ug.edu.gh 2.8.1 Environmental factors Stecker et al. (2013) have reported that disruptive behaviors are very prevalent among nurses. The hospital environment is a complex setting encompassing physical, emotional and psychological factors which could possibly influence the behavior patterns of nurses. According to the U.S. Department of Health and Human Services (2016) the highly stressful nature of the hospital environment is fertile ground for breeding disruptive and uncivil behaviors among health workers, especially nurses, who happen to form the majority of healthcare professionals. Historically, nursing has been perceived as an oppressed group (Farrell, 1997). This is because nursing has been a female dominant profession for a significant period of time, and has been considered to be under the dominance of a “patriarchal” health system which has its heads predominantly being physicians, male healthcare administrators and certain nurse managers who have been marginalized (Farrell, 2001). This oppression among the nursing profession, according to Farrell (2001) results in displaced frustration which is then manifested as violence among co-workers. Further, according to Ford (2009), one of the root causes of disruptive behavior among nurses is conflict within the hospital environment. Differences between expectations and reality, usually in the workplace, result in emotional tension and combative behavior. Conflicts between physicians and nurses; usually because of the presumed superiority of physicians to nurses in the healthcare system; has been cited by Weber (2004) as the most common cause of disruptive behavior. By inference, nurses develop disruptive behaviors out of the frustration resulting from conflicts between their presumed physician “superiors”. 26 University of Ghana http://ugspace.ug.edu.gh Fierlbeck & Palley (2015) reported in a cross sectional study conducted to investigate disruptive and toxic behaviors in healthcare revealed that out of a total of 530 nurses, 25% believed that unpleasant hospital environments were a major trigger of disruptive behaviors among nursing staff. Respondents went on to enumerate unavailability of appropriate work equipment, mortality issues, increased hours of work and the perceived superiority of physicians over nurses, as some environmental factors which could cause nursing staff to behave in uncivil and disruptive manners. These results are consistent with results obtained by McCartan (2004) in his survey to assess the impact of disruptive health worker behavior on quality healthcare delivery. Results of the study revealed that prolonged working hours and unavailability of adequate logistics were among the major environmental causes of disruptive nurse behavior (McCartan, 2004). Berman-Kishony & Shvarts (2015) also reported that extremely high workload on nurses is directly linked to disruptive behaviors in the hospital. According to Arthur (2012), the sort of leadership exerted by healthcare managers within the hospital setting could directly or indirectly influence the sort of behaviors its health workers exhibit. Arthur (2012) found a positive correlation between laissez faire leadership style and disruptive health worker behavior. In laissez faire leadership, healthcare managers are hands-off and allow health workers to make decisions on their own. This form of leadership is thought to be helpful for health workers to understand their strengths and weaknesses and solve problems on their own, based on their level of professionalism, 27 University of Ghana http://ugspace.ug.edu.gh even though healthcare managers still provide the tools and resources needed (Bartunek, 2011). Arthur (2012) however reported that due to the complete freedom given to health workers to make decisions in this form of leadership, staff are able to take the laws into their own hands, and with time begin to exhibit disruptiveness in the healthcare setting. Other environmental factors which have been proven to be significant causes of disruptive behaviors among nurses include poor communication between nurses and the rest of the healthcare team, inadequate ventilation in the wards resulting in stuffiness and reduced concentration and poor lighting conditions which predispose nurses to occupational health and safety issues (Rosenstein, 2009; Stanely, 2010). According to Rosenstein (2008), healthcare facilities which have more pleasant environments, are adequately ventilated and have good lighting settings, are more likely to record less cases of disruptive behaviors among their nursing staff. 2.8.2 Personal factors Causes of nurse disruptive behavior which have been cited in literature are, in part, related to certain personality factors of the individual nurse. Ford (2009) reported that certain individuals, nurses included, naturally possess conflict-prone and borderline personalities which are generally characterized by anger. In his cross sectional study, Ford (2009) reported that nurses with borderline personality are associated with a greater likelihood of disruptive behaviors, including physical treats, in the medical setting. According to Farrell (1997), such personalities expose the disrespectful nature of some nurses towards their 28 University of Ghana http://ugspace.ug.edu.gh colleague nurses, also making such behaviors extend to other members of the healthcare team and even patients. Rosenstein (2009) asserted that generational differences and varying degrees of moral upbringing among nurses and other members of the healthcare team may be a precipitating factor for disruptive behavior. According to him, a person’s experiences, morals, standards, attitudes and preferences are shaped to a large extent by the prevailing events as of the time of their upbringing. For example, nurses who were born between the years 1900 and 1945 who experienced the atrocities of the First World War would have different values from those who were born in 1946-1964 and those who were born in 1981-1999, when technology was experiencing a boost. Rosenstein (2009) went on to say that, coping with these generation gaps and attempting to understand each other’s values and preference is likely to make nurses act in ways that may be considered as disruptive. Gender differences among nurses have also been cited as a cause of disruptive behavior. Studies have shown that globally, about 90% of the nursing population is female while the remaining 10% constitute the male nursing population (Ulrich, 2010). Men have generally been described as being task oriented and working independently, while women on the other hand enjoy social contact and seek for group approval. Such differences among the two sexes may explain why under stress, males become more bullying, while their female counterparts seek for group approval (Longo, 2010). 29 University of Ghana http://ugspace.ug.edu.gh 2.8.3 Behavioral factors Although disruptive behaviors exist in all professions, the problem seems especially prevalent in nursing. Right from the very onset, trainee nurses are exposed to various forms of emotional, verbal and physical abuse by their seniors, both in school and on the ward (Borkowski, 2016). Student nurses get yelled on, laughed at, and ridiculed in front of other nurses and patients, and also observe professional nurses exhibiting disruptive behaviors towards patients Farrell (1997). This, Farrell (1997) referred to as a “regular occurrence”. Due to this, trainee nurses are made to believe that being disruptive is relatively normal in the nursing profession, and thus, the cycle continues. Nurses who survive disruptive behaviors such as bullying early in their careers tend to carry their learned behaviors with them. They accept the bullying culture as part of the job, and either participate in the culture as a bullies or as bystanders (American Medical Association, 2002). reported that, in an oppressed group such as nursing, group members tend to act out against one another because they lack control over their situation. Many healthcare managers consciously or subconsciously promote oppressive conditions such as little recognition of nurses’ ability to think critically and inadequate staffing conditions. Due to the fact that nurses usually cannot verbalize their frustrations to their superiors for fear of punishment, their unexpressed feelings and concerns diminishes their self-esteem and triggers the cycle of oppressed group behavior (disruptive behavior in the work place), which in turn causes more frustration, lack of co-worker support and conflict (Farrell, 1997). 30 University of Ghana http://ugspace.ug.edu.gh Calnan (2005), reported that disruptive behaviors such as bullying and emotional abuse among nurses are a portrayed as a “rite of passage” in the nursing profession. According to him, trainee nurses are bullied and subjected to other forms of disruptive behaviors at the hands of their seniors in school and other professional nurses in the hospital setting. They also observe professional nurses being rude and unpleasant to patients. All experiences with disruptive behavior patterns are encoded in the minds of these junior nurses, who in turn continue the cycle by meting out such behaviors to other trainee/ junior nurses, once they become professionals (Afzali et al., 2015). This concept is termed “Observational Learning” by Bandura (1986). Afzali et al., (2015) went on to report that observation plays a critical role in the perpetuation of workplace violence among nurses. They explained, that when nurses get pleasurable responses or good feelings after engaging in such behavior patterns, they get some sense of fulfilment, which encourages them on other onlookers to continue behaving in disruptive manners towards other nurses, other members of the healthcare team, and even patients. 2.9 Effects of disruptive nurse behavior Disruptive nurse behavior not only threatens patient safety, but also the wellbeing of nurses themselves and their competence in performing their clinical duties. Such behaviors among the nursing workforce could result in errors in medical and nursing procedures, reduced performance of nursing staff, increased staff turnover, disruption in communication among nurses and the resulting in communication problems in the rest of the medical team, 31 University of Ghana http://ugspace.ug.edu.gh reduction in patient satisfaction, and ultimately reduced patient outcomes (Griffin, 2004; Joint Commission, 2008; Berman-Kishony & Shvarts, 2015). Rosenstein & O’Daniel in 2005 conducted a study to examine the prevalence and impact of health worker disruptive behavior on the job. The study examined disruptive behavior among both physicians and nurses within the healthcare setting. It also sought to unearth the perceptions of the effects of disruptive behavior on nurses and physicians and its impact on clinical outcomes. Results indicated that most of the disruptive behavior is perceived as having negative effects on both nurses and physicians. These negative effects include stress, frustration, decreased concentration levels, reduced communication, collaboration, information transfer among physicians and nurses, and marred workplace relationships. More disturbing effects of disruptive behavior among nurses and physicians include adverse events, medical errors, compromised patient safety, patient mortality, less than optimal quality of care, and reduced patient satisfaction. The same authors, Rosenstein & O'Daniel conducted a study in 2008 to assess the significance of disruptive behavior among nurses and other health workers and its impact on communication and collaboration among health workers, and the ultimate impact on patient care and health outcomes. The results from the survey revealed that disruptive behaviors led to potentially avoidable adverse effects on patients and other members of the health team. Further, adverse effects resulting from compromises in patient safety and medical errors together with a reduction in quality of care rendered, and in some cases, death of patients, were recorded as resulting from disruptive behaviors among nurses. 32 University of Ghana http://ugspace.ug.edu.gh Jericho, Mayer, & McDonald, (2010) also asserted that disruptive behavior among healthcare members is a documented problem which is known to be of frequent occurrence in healthcare institutions. According to them, disruptive behaviors have a negative effect on concentration of clinical staff, communication and collaboration among healthcare professionals, and marred workplace relationships. Because of these negative effects, disruptive behaviors have been linked to suboptimal patient health outcomes, compromised patient safety, and patient death in extreme cases. 2.10 Remedying disruptive behaviors among nurses in healthcare organizations Disruptive behavior among nurses is nothing new. The problem however lies in the fact that little has been done in the past to address this phenomenon. To effectively manage the occurrences of disruptive behavior among nurses, it is first and foremost imperative to have a nursing and hospital leadership which is committed to the cause and willing to met out sanctions to nurses who are caught perpetuating disruptive behaviors (Rosenstein, 2009). To minimize the occurrence of disruptive behavior, several strategies and guidelines have been spelt out by some healthcare organizations. Despite these guidelines however, disruptive behaviors among nurses continue to be an ever-increasing worldwide healthcare safety concern. In their study, Jericho, Mayer and McDonald (2010) described the most common types of disruptive behaviors; including their various prevalence and frequency rates, including their distribution in the various sectors of the healthcare system. They also 33 University of Ghana http://ugspace.ug.edu.gh recognized the factors that influence disruptive behavior and their effects on patient and health worker safety. Further, they illustrated the organizational processes employed in addressing disruptive behaviors. The authors believed that in order to minimize the occurrence of such behaviors, there must be increased awareness of disruptive behavior and the various organizational processes which have been put in place by healthcare institutions to minimize these behaviors. This, according to Jericho, Mayer and McDonald (2010) will also improve effective communication among members of the healthcare team and eventually lead to improvements in patient health outcomes and safety, as well as bring about general improvements in health sector effectiveness. The International Society of Psychiatric Mental-Health Nurses (2014) outlined some remedial measures that can be put in place by healthcare organizations in the bid to curtail the incidence of disruptive behaviors among nurses in the workplace. First and foremost, the ISPN suggested re-enactment of codes of behavior and no tolerance policies in health institutions, in order to promote the culture of safety against disruptive behaviors. Notwithstanding the fact that codes of behavior and zero tolerance policies against disruptive behaviors will go a long way to ensure nurse and patient safety, Hader (2008) reported that respondents of his study who had such policies enforced in their institutions believed that they were not effective. According to him, one nurse manager is reported as saying “We do have a zero-tolerance policy in place, but nothing happens if violence occurs. We’re frequently assaulted by our patients”. Other nurses are also reported to have said that such zero tolerance policies are just “lip service”, and are not enforced especially 34 University of Ghana http://ugspace.ug.edu.gh when the culprit of the disruptive behavior towards the nurse is a physician. That goes to say that, even though having codes of behavior and anti-disruptive behavior policies may control such behavior among nurses to an extent, it is not an ultimate solution to the problem. Secondly, engaging all staff in educational programs on disruptive behavior in the hospital has been recommended by the International Society of Psychiatric Mental-Health Nurses, (2014) towards remedying disruptive behavior among nurses. The authors believed that making such educational programs interactive and compulsory for all staff, will go a long way to reduce the incidence of such behaviors. Lastly, the ISPN (2014) recommended that expectations should set such that various unit heads will develop ways to educate and support their staff so as to prevent disruptive behaviors from unconsciously becoming a norm in their various units (International Society of Psychiatric Mental-Health Nurses, 2014). The survey conducted by Hader (2008) revealed that 80% of health employers sampled reported to have employee assistance programs available to help nurses and other health professionals with respect to disruptive behaviors. In such programs, managers refer nurses who are either victims or perpetuators of such behaviors to behavioral health specialists for specialist treatment. 35 University of Ghana http://ugspace.ug.edu.gh Berman-Kishony & Shvarts (2015) reported that many nurses who engage in disruptive behavior are mostly unaware of their actions. They mostly do not think their actions have any negative effect of themselves, their colleague nurses and their patients. Therefore, in managing disruptive behavior among nurses, it is important to first of all make the offenders aware of such behaviors they may be exhibiting unknowingly, and also try to unravel the root cause of the problem. Longo (2010) identified that disruptive behaviors which are perpetuated by healthcare professional can have detrimental effects on both the patient and the healthcare professional. The author stressed that disruptive behaviors in healthcare must no longer be tolerated. As such, healthcare institutions must adopt a zero-tolerance position towards handling these behaviors. This, according to Longo (2010) is the first step towards curbing these behaviors. According to him, improving general communication skills of health workers which will in turn increase their desire to communicate effectively, formulating health policies concerning disruptive behaviors, and fostering healthy interactions with other healthcare professionals are also important in curbing disruptiveness in healthcare. Longo, (2010) concluded by saying that in order to maintain a safe and healthy hospital environment, assertiveness among healthcare professionals must be encouraged. As such, all health workers have the mutual responsibility of acting in a professional manner. Health workers also have the right to expect non-disruptive treatments from their colleagues. 36 University of Ghana http://ugspace.ug.edu.gh 2.11 Educational qualifications and behavior patterns of nurses Disruptive behaviors among nurses, as compared to assertive behaviors, have received immense attention over the years. Studies on behavior patterns among nurses have suggested that education serves as a powerful tool in ensuring that nurses remain assertive in their daily dealings with patients, colleague nurses, and other members of the health team. These studies have suggested a positive relationship between educational qualifications of nurses and positive nurse behavior patterns (Rosenstein & O’Daniel, 2008; Veltman, 2007; Strauss, 2008). As a result, a variety of ways have been suggested by which education can be used as a tool to address disruptive behaviors among nurses, while promoting assertive behaviors. Rosenstein (2002) reported in his study that adopting educational measures was a needed strategy in the fight of curbing disruptive behaviors among nurses. According to this study, 24% nurses who were sampled reported that equipping nurses with the needed educational tools was that a needed strategy in the bid to decrease disruptive behaviors. In allowing nurses to better educate themselves, they would acquire the necessary skills which will enable them improve their working relationships with fellow nurses, patients and other members of the health team. In the same vein, Griffin (2004) also asserted that newly qualified nurses who had received a high level of training on the use of cognitive techniques in dealing with disruptive behaviors are better able to deal with colleague nurses who displayed violence in the workplace. 37 University of Ghana http://ugspace.ug.edu.gh In a qualitative study conducted by MacIntosh (2006) to study bullying among nurses, 21 nurses in a mental health institution reported that educating nurses provides them with increased knowledge about the nature and forms of bullying among nurses. It also makes them aware of the terms and services available for nurses who may have experienced any form of bullying from colleague nurses or other members of the health team. These, according to MacIntosh, would aid in combatting disruptiveness among nurses. Educating nurses has also been reported by Rosentein (2002) to providing nurses with the required incentives and serving as a needed strategy curbing disruptive behaviors. According to Rosentein, increased educational levels provide nurses with the requisite knowledge to improve their working relationships with colleague nurses, patients, and other members of the health team. A qualitative study conducted by MacIntosh (2006) to study bullying among nurses revealed allowing nurses to better educate themselves will provide nurses with knowledge regarding the nature and effects of bullying and in effect, serve as a powerful tool in combatting bullying. 2.12 Theoretical and conceptual frameworks for the study The Theoretical Framework on which thus study is based is the Social Cognitive Theory propounded by Albert Bandura (1986). The Social Cognitive Theory is one of the dominant tenets in Organizational Behavior (Organizational Psychology). The study further conceptualizes the Model of Reciprocal Determinism, which is one of the major principles of the Social Cognitive Theory, in explaining the factors pertaining to disruptive nurse behavior. The model is then adapted to encompass the hospital environment, the 38 University of Ghana http://ugspace.ug.edu.gh personality of the nurse, and behavioral factors which continuously interact in a particular manner, resulting in nurses eliciting disruptive behavior. 2.13 The Social Cognitive Theory; Albert Bandura, (1986) The Social Cognitive Theory is a development on the Social Learning Theory (Bandura, 1971) and has been largely used in Organizational Psychology. This theory was found to be useful in the sense that it explains psychosocial functioning in terms of the individual’s personal characteristics, their environment and observational learning including group behavior, as is believed to be in the case of nurses. In the Social Cognitive theory, Bandura holds the view that an individual’s acquisition of a particular behavior pattern can be directly linked to observing others within the context of social interactions and experiences. When people observe a particular behavior being carried out, they remember the sequence of events and use this information to guide subsequent behaviors. This, he termed as “Modeling”. Observing a behavior being performed can also prompt the viewer to engage in behavior which has already been leant. Bandura asserted that learning is affected by behavioral, cognitive and environmental factors, and that human thought processes are central to understanding human behavior. Learning, in this context, is defined as a relatively permanent change in behavior, due to experience (Anderson, 2011). In the Social Cognitive Theory, Bandura places emphasis on social influence together with external and internal reinforcements. The key concepts propounded in the Social Cognitive Theory are: 1. Reciprocal Determinism: the dynamic and reciprocal interaction of a person, their environment and other behavioral factors. Bandura posited that humans are neither solely 39 University of Ghana http://ugspace.ug.edu.gh driven by inner forces, nor automatically controlled by external stimuli. Human functioning is rather explained in terms of a model of triadic reciprocal determinism. In this model, behavioral, personal and environmental factors are portrayed as interacting determinants of each other. The nature of person and the attitudes they exhibit is then defined within this triadic perspective. Behavioral Personal Environment Figure 2.1 Model of Reciprocal Determinism (Bandura, 1986) The term “reciprocal” refers to mutual action, whilst determinism refers to the production of effects, which is the resulting behavior pattern. Within this triad, there is a continuous interplay between self-generated and external sources of influence. 2. Behavioral Capability: a person’s actual ability to perform a behavior through essential knowledge and skills. In order to successfully perform a behavior, a person must know what to do and how to do it. People learn from consequences of their behavior, which also affects the environment in which they live. 40 University of Ghana http://ugspace.ug.edu.gh 3. Observational Learning: people can witness and observe and observe a behavior conducted by others, and then reproduce those actions. This is often exhibited through “modeling” of behaviors. If individuals see successful demonstration of a behavior, they can also complete the behavior successfully. 4. Reinforcements: this refers to the internal or external responses to a person’s behavior that affect the likelihood of continuing or discontinuing the behavior. Reinforcements can be self-initiated or in the environment. They can also be positive or negative. 5. Expectations: this refers to the anticipated consequences of a person’s behavior. People anticipate the consequence of their actions before engaging in the behavior, and these anticipated consequences can influence successful completion of the behavior. Expectations drive largely from past experience. 6. Self-Efficacy: this refers to the level of a person’s confidence in his or her ability to successfully perform a behavior. Self-efficacy is influenced by a person’s specific capabilities and other individual factors, as well as by environmental factors. Central to the concept of disruptive behaviors among nurses is the concept of Reciprocal Determinism which captures other concepts such as Observational Learning and Reinforcements. The model is operationalized, together with the review of empirical literature, into the conceptual framework in Figure 2.2 to include the hospital environment, which is the working environment of the nurse, personal characteristics and behavioral factors in explaining disruptive nurse behavior. 41 University of Ghana http://ugspace.ug.edu.gh Figure 2.2 Conceptual framework Behavioral factors Environmental factors Direct Disruptive Unpleasant Leadership observation group hospital style, private/ of disruptive behavior environment public behaviors Self efficacy Inadequate ownership Poor Practice ventilation lighting condition s Standards Morals Personality factors Education Values Disruptive nurse behavior Negative patient health out comes, medico legal issues, death Internal reinforcements External reinforcements Long term behavior modification (Assertive behavior) 42 University of Ghana http://ugspace.ug.edu.gh 2.14 Reciprocal determinism applied to the study In reciprocal determinism, Bandura placed the environment within a triad which interacts with other factors to elicit a particular behavior in an individual. Afzali et al., (2015) asserted that an unpleasant working environment within the hospital setting is a risk factor for disruptive behavior among health workers. Conditions which affect the physical working environment such as poor lighting, noise, and poor ventilation could serve as contextual factors which could increase the likelihood of health workers engaging in disruptive behaviors. Nyarko (2015) also reported that another factor within the healthcare environment which could attribute to nurses engaging in disruptive behaviors is the kind of leadership style which is exhibited in the facility. According to Afzali et al., (2015), Laissez-faire leadership is also strongly correlated with disruptive behaviors. At another end of the Reciprocal Determinism Triad is “Behavioral factors”. This concept was explained by Bandura as being directly linked to observing others within the context of social interactions and experiences. This is consistent with Anderson (2012) who observed that nurses learn to become disruptive when they observe fellow nurses engaging in equally disruptive behaviors. According to Calnan (2005), disruptive behaviors such as bullying and emotional abuse are a seeming “rite of passage” in the nursing profession. Right from school, trainee nurses are bullied and subjected to other forms of disruptive behaviors at the hands of other professional nurses. They also observe professional nurses being rude and unpleasant to patients. Trainee nurses in turn encode all these behavior patterns; consciously or subconsciously; assume they are normal within the profession, and in turn, continue the vicious cycle of disruptive behaviors among nurses (Afzali et al., 43 University of Ghana http://ugspace.ug.edu.gh 2015). Further, when nurses get pleasurable responses or good feelings after engaging in such behavior patterns, the behavior is likely to repeat itself. Thirdly, the triad depicts the personal factors of the individual nurse; their thoughts and beliefs regarding disruptive behavior. According to Bandura (1986), a person’s values, standards and morals are what control the person’s cognition with regards to behaving in a particular manner. Self-condemnation for violating personal values, functions as a deterrent against inappropriate behavior. However, individuals find it easier to engage in disruptive behaviors if they can defend their behaviors it morally through a process called moral disengagement (Bandura, 1986). Moral disengagement is the process of convincing oneself that certain moral principles do not apply to oneself in a particular situation (Bandura, 1999). In order for disruptive behavior among nurses to be remedied, reinforcements must be applied both internally and externally (Afzali et al., 2015). Reinforcements have earlier on been explained as responses to a person’s behavior that affect the likelihood of continuing or discontinuing the behavior (Bandura, 1999). 2.15 Chapter summary This chapter presented a detailed review of literature related disruptive behavior among nurses in the healthcare setting. It has been established that nurses play a highly indispensable role in the healthcare system. Due to the fact that nurses spend more time with patients, their (nurses) behaviors affect patients in numerous ways. Disruptive nurse behavior has been reported as a major problem in western healthcare literature, but same 44 University of Ghana http://ugspace.ug.edu.gh cannot be said about literature in the Ghanaian context. Disruptive behavior results in negative patient outcomes. The services of nurses are employed by both private and public healthcare institutions and thus, patients have the liberty to choose between public and private hospitals when seeking healthcare. Some studies have shown varying levels of disruptiveness among nurses. It is therefore imperative, as this study seeks to do, to compare levels of disruptive behavior among nurses in private and public healthcare institutions, so as to find ways to mitigate disruptive behavior whiles encouraging assertive behavior, in order to ensure optimal patient health outcomes. 45 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 METHODOLOGY 3.1 Introduction The chapter on methodology in this study basically describes the procedure(s) used in data collection and how the data was analyzed. The main sections of the chapter include a description of how the target healthcare institutions were identified, the research design used and a description of the population for the study. The chapter also presents the sampling technique used, determination of sample size, and description of research instrument used. The final sections of the chapter include the research assumptions, statistical analysis and ethical considerations employed for the conduct of this study. 3.2 Identification of target healthcare institutions Ghana has a dual healthcare system made up of the public sector and the private sector. The public sector comprises government health institutions while the private sector, comprises both for-profit and not-for-profit organizations. For the purpose of this study, two public and four private hospitals were purposively selected as was the case in Rojas (2014). The rationale behind selecting four public hospitals and two private hospitals is that the public hospitals are generally bigger in size and have a larger number of nursing staff, as compared to the private hospitals. They are also known to provide a relatively larger array of healthcare services to their clientele. All these factors are believed to have a bearing on behaviors exhibited by nursing staff Canvanah et al., (2012). As such, it would be biased on the part of the researcher to consider an equal number of public and private 46 University of Ghana http://ugspace.ug.edu.gh hospitals. It is believed that these factors may have a significant bearing on the findings which will be arrived at. The public hospitals for the purpose of this study are Achimota Hospital and Shai-Osudoku District Hospital. Achimota hospital is located at Achimota in Accra, while the Shai- Osudoku District Hospital is located in Dodowa. The Private Hospitals are Medifem Hospital & Fertility Center, Empat-Claiquo Hospital, FOCOS Orthopedic Hospital and Dar-Bem Medical Center. Medifem Hospital & Fertility Center is located at West Legon, Empat-Claiquo Hospital is located at Community 6, Tema, Dar-Bem Medical Center is located at Ashiaman, and FOCOS Orthopedic Hospital is located at Pantang West. These hospitals purposively selected because they are all located within the heart of the Greater Accra Region and as such, are in close proximity to the researcher. This will thus make data collection more convenient. Also, the selected hospitals are known to have in their employment, the appropriate number of nursing staff to make up the sample for the study. Further, the researcher is aware of undocumented complains from some patients of seemingly unacceptable behaviors being carried out by some nurses in the selected hospitals. 3.3 Research design The study aimed at comparing disruptive behavior patterns exhibited by nurses in public and private healthcare institutions. It relied on a Cross-Sectional Survey design. The Cross- sectional Survey is an observational research design, which means that the researcher reports information about the study respondents without manipulating the study environment (Wallen & Frankael, 2006). The study sought to take advantage of this feature of the Cross-sectional Survey design in adequately testing objective 1 of the study, which 47 University of Ghana http://ugspace.ug.edu.gh sought to identify the disruptive behavior patterns exhibited by nurses, this feature was also suitable for objective 3 aimed at determining the relationship(s), if any, between educational qualification of nurses and disruptive behavior, using the Spearman’s Rank Correlation Coefficient (ρ) as was the case in Wang (2017). These objectives aimed at merely describing the existing situation of disruptive behaviors among nurses in these facilities at a particular point in time, without manipulating the study environment, which is the hospital setting. Institute for Work & Health (2015) also outlines the defining features of a cross-sectional survey to include the fact that it is capable of comparing dissimilar population groups and variables at a single point in time. This feature of the study design was deemed as suitable for objective 2, which aimed at comparing the behavior patterns identified. Further, this study also wished to take advantage of the fact that cross sectional surveys are relatively quicker and cheaper, as stated by Mann (2003). There is also no follow up required, and relatively fewer resources are required to conduct such a survey. 3.4 Population of the study The target population for the study was all professional nurses in the Greater Accra Region of Ghana. This was made up of registered nurses from the public and private hospitals respectively. The sample population consists of professional nursing staff of the target healthcare institutions earlier identified in the Greater Accra region. According to Ministry of Health (2013), the total number of nurses in the Greater Accra region as of 2012 numbered 4,649. This figure is however a representation of the number of nurses on government payroll. The total number of nurses in the private sector however remains undocumented. This could be due to the fact that the private health sector is highly 48 University of Ghana http://ugspace.ug.edu.gh unregulated and as such, figures regarding staffng in these privately owned health facilities are not readily available. Due to the unavailablity of reliable figures pertaining to the total number of nurses in private and public hospitals in the Greater Accra Region of Ghana, the Accessible Population from the target hospitals listed in the previous paragraph were attained and used as an estimate for the population of the study. Accessible population, according to Fraenkel & Wallen (1993), is the total number of people to which the researcher is able to generalize research findings. According to Fraenkel & Wallen, the target population to which the researcher would ideally want to genralize their findings is often unavailable, as in the case of the total number of nurses in the Greater Accra Region. The total accessible population of 454 nurses was thus arrived at by addition of the total number of professional nurses in the target institutions. A breakdown is illustrated in Table 3.1. Table 3.1 Accessible population for the study Name of Hospital No of Professional Nurses Achimota Hospital 141 ShaiOsudoku District Hospital 152 Medifem Hospital & Fertility Center 55 Empat-Claiquo Hospital 31 FOCOS Orthopedic Hospital 35 Dar-Bem Medical Center 40 Total 454 Source: Study Data (From In-Service Training Units of the various facilities), (2017) 49 University of Ghana http://ugspace.ug.edu.gh 3.5 Sample size A table for the determination of sample size from a given population (NEA Research Bulletin, 2005) was used to read the minimum sample size of 209. This was rounded up to 210 and distributed equally (105 each) between the public and private healthcare institutions. 3.6 Sampling technique After the purposive identification of the target healthcare institutions, a simple random sampling process was used to select 105 respondents from each of the group of public and private healthcare institutions thus arriving at a sample size of 210 respondents. According to Wallen & Frankael, (2006), simple random sampling could be used where a sample frame (such as a predetermined population) is available during a sampling process. Simple random sampling technique allows every member of an accessible population to have an equal and independent chance of being selected into a sample. 3.7 Data collection instrument A 36 item close ended questionaire structured into four sections was used to conduct the cross-sectional survey. Responses were categorised into a 4 point likert scale. Part one of the questionnaire explored the demographic information of the sampled nurses in the two categories of healthcare institutions (private and public). Part two gathered information on the various forms of nurse to nurse behaviors. Part three gathered information on nurse to patient behvaiors. Part four gathered information on other kinds of behaviors exhibited by nurses. Data collection was conducted by self administration of the questionnaires by the researcher. This was done in order to ensure a high response rate from the respondents. 50 University of Ghana http://ugspace.ug.edu.gh After completion of the questionnaire by respondents, the responses were then coded for analysis. 3.8 Ensuring validity and reliability The questionnaire items were validated by the Thesis Superviror and a pilot study carried out in Winneba Government Hospital (a public hospital) and Otoo Memerial Hospital (a private hospital) all in the Central Region. These hospitals were chosen because of proximity to researchers’ residence and cost implications. Cronbach Alhpa coefficient was used to determine the reliability of the questionnaire items after the pilot study. A coefficient of 0.894 was arrived at, indicating a high level of internal consistency of the research instrument. 3.9 Identification of behavior patterns The various forms of disruptive behaviors which were included as items on the questionnaire were first of all identified from literature. After an extensive review of literature, it was identified that certain forms of nurse behaviour were in existence in healthcare institutions. Such behaviors were included in the questionnaire for the pilot study. After the pilot study however, other behaviors were identified which enabled the Reseracher to modify the instrument. That goes to say that the items on the questionnaire were derived from both literature and the pilot study. 3.10 Statistical analysis Data was analyzed using SPSS software version 20 through descriptive statistics such as measures of central tendencies, and inferential statistics such as Spearman’s Rank 51 University of Ghana http://ugspace.ug.edu.gh Correlations and Mann-Whitney U tests. These statistical tools were also used to establish averages, differences, similarities and relationships in behavioral patterns. The findings were presented in tables and charts. 3.11 Ethical consideration Approvals for data collection were obtained from the Department of Public Administration and Health Services Management, the hospitals’ administrators and nurses. Participant anonymity and confidentiality were ensured by using numerical codes for questionnaires, and destroying all data collected, at the end of the study. 3.12 Chapter summary This chapter presents the research methodology employed for this study. The Cross- Sectional Survey design was used to quantitatively compare disruptive behaviors among nurses in public and private healthcare institutions in the Greater Accra Region, Ghana. A total of 6 hospitals (2 public and 4 private) were identified and selected as the target healthcare institutions. The study then employed simple random sampling to select 210 nurses (105 from each category of healthcare institution), who formed the participants for the study. Approval for data collection was sought from the Department of Public Administration and Health Services Management, and from the leadership of the target healthcare institutions. A 36 item close ended questionnaire was developed using the researcher’s own construct and was used as the data collection instrument. Participant anonymity and confidentiality were ensured. 52 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 PRESENTATION OF RESULTS 4.1 Introduction This chapter seeks to present the results of data analysis. Data was analyzed to address the research objectives together with the hypothesis which was earlier on outlined in the previous chapters. A Cross-Sectional Survey approach was used to compare the various disruptive behavior patterns which were identified in literature and in the pilot study. A total of 210 nurses who formed the respondents for the study were randomly selected from a total of 6 (2 public and 4 private) purposively identified healthcare institutions in the Greater Accra Region of Ghana. Data was analyzed using SPSS version 20. The chapter begins with presentation of results relating to demographic characteristics of nurses in private and public healthcare facilities in the Greater Accra Region, Ghana. It then goes on to present the results of data analysis for the various research objectives and hypothesis. 4.2 Presentation and analysis of findings This section presents the results of data analysis and findings of the study. The section begins with the demographic characteristics of the respondents and continues with analysis of data with respect to the various objectives and hypothesis of the study. 53 University of Ghana http://ugspace.ug.edu.gh 4.3 Demographic characteristics of nurses To compare the various disruptive behaviors exhibited by nurses in private healthcare institutions with that of nurses in public healthcare institutions, the study examined the demographic data of nurses in both public and private healthcare facilities, in the bid to relate it to the behaviors they exhibit. Table 4.1 Gender distribution of nurses in private healthcare institutions G ender Frequency Percentage (%) Male 24 22.9 Female 81 77.1 Total 105 100.0 Source: Study Data, (2017) Table 4.1 presents the gender distribution of nurses in private healthcare institutions.1This goes to show that there are more female nurses than male nurses in the private sector. Table 4.2 Gender distribution of nurses in public healthcare institutions GENDER FRENGUENCY PERCENTAGE (%) Male 39 37.1 Female 66 62.9 Total 105 100.0 Source: Study Data, (2017) 1Out of a total sample size of 210, 105 of the respondents were nurses who are currently practicing in privately owned healthcare institutions. From table 4.1, it is observed that 24(22.9%) of the private sector nurses were male, while 81(77.1%) of the nurses were female 54 University of Ghana http://ugspace.ug.edu.gh Table 4.2.2 presents the gender distribution of nurses in public healthcare institutions.2 Comparing table 4.1 with table 4.2 however, it can be observed that the number of male nurses in the public healthcare institutions 39(37.1%) is greater than the number of male nurses in the private healthcare institutions 24(22.9%). Further, the female nurses in the private healthcare institutions 81(77.1%) outnumber the female nurses in the public healthcare institutions 66(62.9%). It can be inferred from tables 4.1 and 4.2 therefore, that the public healthcare institutions in the Greater Accra Region of Ghana have in their employment more male nurses as compared to the private healthcare institutions. On the other hand, private healthcare institutions in the Greater Accra region of Ghana tend to employ more female nurses than public healthcare institutions in the Greater Accra Region of Ghana. It is important however to note, that literature is silent on this issue. Table 4.3 Age distribution of nurses in private healthcare institutions Age Frequency Percentage (%) 18-25yrs 29 27.6 26-33yrs 52 49.5 34-41yrs 11 10.5 42-49yrs 5 4.8 50-57yrs 3 2.9 58-60yrs 5 4.8 Total 105 100.0 2Out of the 105 nurse respondents in the public sector, 39(37.1%) of them were male, while 66(62.9%) were female. 55 University of Ghana http://ugspace.ug.edu.gh Source: Study Data, (2017) Table 4.3 presents the age distribution of nurses in private healthcare institutions.3 Private healthcare institutions in the Greater Accra Region of Ghana can, from table 4.3, be said to have a relatively youthful nursing staff. Table 4.4 Age distribution of nurses in public healthcare institutions Age Frequency Percentage (%) 18-25yrs 15 14.3 26-33yrs 77 73.3 34-41yrs 7 6.7 42-49yrs 3 2.9 50-57yrs 3 2.9 58-60yrs 0 0 Total 105 100.0 Source: Study Data, (2017) Table 4.4 presents the age distribution for nurses in public healthcare institutions.4 This table shows that the public sector has in its employment a relatively youthful nursing population. 352(49.5%) of the private nurses fell between the ages of 26 and 33 years. 18 to 25 years which constituted 29(27.6%) and ages 34 to 41 years, which constituted 11(10.5%) of the private hospital nurses. The remaining age groups recorded less than 5% of the sample size. The mean age for the distribution was 2.25years and the standard deviation of 1.3. 4the age group of 26-33 years had 77(73.3%) respondents. Followed by 18-25 years which constituted 15(14.3%), 34-41 which constituted 7(6.7%) of the sample size for the public sector. The remaining age 56 University of Ghana http://ugspace.ug.edu.gh Table 4.5 Qualification distribution of nurses in private healthcare institutions Qualification Frequency Percentage (%) Doctorate 4 4 Masters 1 1 BSc 15 14.3 BA 2 1.9 Advanced diploma 11 11 Diploma 16 15.2 Certificate 56 53.3 Total 105 100 Source: Study Data, 2017 Table 4.5 presents the educational qualifications of nurses in private healthcare institutions.5 From the table, it can be seen that the private healthcare institutions tend to have in their employment more nurses with Certificate (2 years of basic nursing training) as compared to other educational qualifications. This could partly be attributed to the fact that the institutions in question find it relatively cheaper to pay these Certificate nurses as compared to the Diploma holders and other categories of nurses. groups, ages 42-49years and 50-57years, recorded less than 3% each, and ages 58-60 years had no respondents. The mean age for the public sector nurses was 2.07 years and the standard deviation was 0.76. 556(53.3%) have Certificate in nursing. (15.2%) who possess a Diploma. 15(14.3%) who possess a BSc and 11(10.5%) possess an Advanced Diploma. The remaining qualifications recorded less than 5% of the population each, with BA in nursing recording 2(1.9%), Masters recording 1(1.0%), and Doctorate in Nursing with 4(3.8%). 57 University of Ghana http://ugspace.ug.edu.gh The low number of nurses who possess Advanced Diploma and Masters Qualifications and the fact that none of the nurses in the public sector was reported to have a Doctorate degree is also an indication of the little number of nurses who possess a higher degree. Table 4.6 Number of years of practice in the private sector Number of years Percentage (100%) <2yrs 22.9 2-5yrs 49.5 5-10yrs 15.2 10-15yrs 2.9 15-25yrs 1.0 >25yrs 8.6 Total 100.0 Source: Study Data, (2017) Table 4.6 presents the number of years of practice for nurses in the private healthcare institutions identified.6These statistics tend to show that there a less nurses with many years of experience in the private sector. 62-5 years represented 52(49.5%), less than 2 years who formed 24(22.9%), 5-10 years followed with 16(15.2%) and above 25 years formed 9(8.6%). 10-15years and 15-25years both recorded less than 3% respectively. The mean duration of practice for nurses in the private healthcare institutions was 2.35years and the standard deviation was 1.36. 58 University of Ghana http://ugspace.ug.edu.gh Table 4.7 Number of years of practice in the public health sector Number of years Frequency Percentage (%) <2yrs 15 14.3 2-5yrs 64 61.0 5-10yrs 19 18.1 10-15yrs 3 2.9 15-25yrs 1 1.0 >25yrs 3 2.9 Total 105 100.0 Source: Study Data, (2017) Table 4.7 presents the number of years of practice for nurses in the public healthcare institutions which were identified.7 From the above, it is even the more evident that the public healthcare institutions are constituted by a relatively younger nursing workforce. This is due to the fact that majority of the nurses have practiced for between 2-5 years. This is also consistent with the mean duration of practice which is 2.24years. In comparison with the private healthcare institutions, there is a similarity in the sense that for both types of institutions, the majority of nurses have been practicing for between 2-5years. 7. 64(61.0%) had practiced between 2-5years, 19(18.1%) had practiced between 5-10years. less than 2 years formed 15(14.3%), 10-15 and greater than 25years formed 3(2.9%) of the sample respectively. Nurses who had served for 15-25years however formed 1(1.0%) of the sample. The mean number of years of practice for nurses in the public healthcare institutions was 2.24years and the standard deviation was 0.97. 59 University of Ghana http://ugspace.ug.edu.gh Table 4.8 Number of promotions in the private sector Number of times promoted Frequency Percentage (%) more than 3 times 6 5.7 three times 5 4.8 twice 16 15.2 once 35 33.3 never 43 41.0 Total 105 100.0 Source: Study Data, (2017) Table 4.8 presents the number of times nurses in the private healthcare institutions identified have been promoted. 8 The table above shows that promotions have been infrequent among nurses in the private healthcare institutions which were identified. Table 4.9 Number of promotions in the public sector Number of time promoted Frequency Percentage (%) more than 3 times 2 1.9 three times 4 3.8 twice 7 6.7 once 32 30.5 never 60 57.1 Total 105 100.0 Source: Study Data, (2017) 843(41.0%) of the nurses have never been promoted. 35(33.3%) have been promoted once, 16(15.2%) have been promoted twice, 6(5.7%) have been promoted more than 3 times and 5(4.8%) have been promoted three times. 60 University of Ghana http://ugspace.ug.edu.gh Table 4.9 presents the number of times that nurses in the public sector have been promoted.9The table shows that promotions among nurses have been less frequent in the public sector. This could be due to the fact that majority of the nurses had practiced for 2- 5 years as shown in table 4.7. It could also be associated with the fact that a large proportion of the nurses in the public sector fall between the ages of 26-33 years as illustrated in table 4.5. Comparing tables 4.8 and 4.9, it is seen that promotions have been infrequent among nurses in both the private and public healthcare institutions. This is evidenced by the fact that majority of the nurses have never been promoted. Notwithstanding the fact that promotions have been infrequent in both sectors, it is observed that promotions are relatively more frequent in the private sector as compared to the public sector. Table 4.10 Previous hospitals that nurses in the private sector have worked in Previous hospital type Frequency Percent Private 45 42.9 Public 40 38.1 Not applicable 20 19.0 Total 105 100.0 Source: Study Data, (2017) 960(57.1%) of nurses have never been promoted. 32(30.5%) have been promoted once. 7(6.7%) had been promoted twice, promoted 3 times numbered 4(3.8%) and those promoted more than three times numbered 2(1.9%). 61 University of Ghana http://ugspace.ug.edu.gh Table 4.10 shows the type of hospitals that nurses in the private sector have previously worked with.10 Table 4.11 Previous hospitals that nurses in the public sector have worked in Previous hospital type Frequency Percentage (%) Private 20 19.0 Public 28 26.7 Not applicable 57 54.3 Total 105 100.0 Source: Study Data, (2017) Table 4.11 shows the previous hospitals in which nurses in the public sector have worked.11 Figure 4.1 Category of nurses in the private sector Category of nurse General nurse Mental Nurse Community nurse midwife Source: Study Data, (2017) 1045(42.9%) of the nurses have worked with other private hospitals in the past, whiles 40(38.1%) of the nurses had previously worked in public hospitals. 20(19.0%) of the nurses had not worked in any hospital previously 1157(54.3%) had not worked in any previous healthcare facility, 28(26.7%) previously worked in other public healthcare institutions, 20(19.0%) previously worked in private institutions. 62 University of Ghana http://ugspace.ug.edu.gh Figure 4.1 above presents the various categories of nurses who work in the private healthcare institutions which were identified. 12 The graph thus shows that the private healthcare institutions employ the services of general nurses as compared to other categories of nurses. Figure 4.2 Category of nurses in the public sector categories of public sector nurses General Nurse Mental Nurse Community Nurse Midwife Other Source: Study Data, (2017) Figure 4.2 presents the categories of nurses who work in the public healthcare institutions.13 12 78(74.3%) of nurses were general nurses, followed by 15(14.3%) who were community health nurses, 7(6.7%) were midwives, 5(4.8%) were Mental/Psychiatric nurses. Other categories of nurses recorded 0(0.0%). 13 90(85.7%) of the nurses were general nurses, 6(5.7%) were community health nurses, 4(3.8%) were midwives and 3(2.9%) who were mental health nurses. Other categories of nurses recorded 2(1.9%). 63 University of Ghana http://ugspace.ug.edu.gh Comparing Figure 4.1 and Figure 4.2, it can be seen that both sectors in the healthcare industry have a nursing population which comprises a majority of general nurses (RGN and EN), followed by community health nurses, midwives, then mental health nurses in that order. Also, it is observed that the public healthcare institutions employ the services of other categories of nurses (ophthalmic nurses, Ear Nose and Throat nurses and Critical Care Nurses) as compared to the private healthcare institutions. 4.4 Identification of disruptive behaviors among professional nurses in the private and public healthcare institutions in the Greater Accra Region, Ghana. This study sought to compare disruptive behaviors among nurses in the Greater Accra Region. For the purpose of achieving this main objective, the first specific objective sought to identify the various forms of disruptive behaviors that are exhibited in private and public healthcare institutions in the study area. The responses for the questionnaire were based on a 4 point Likert scale, which categorized participant responses as follows: Always – 1, Sometimes – 2, Once – 3, Never – 4. 4.4.1 Identification of behavior patterns among professional nurses in private healthcare institutions in the Greater Accra Region, Ghana The 28 behavior types which were identified were each given a weight of 3.57 1 i.e.{ × 28}. The mean response for each behaviour type was computed and rounded up 100 to the nearest whole number to determine whether that disruptive behaviour type was present or absent among nurses in the private healthcare institutions identified. 64 University of Ghana http://ugspace.ug.edu.gh Table 4.12 Behavior patterns of nurses in private healthcare institutions Ser Behavior type No. of Weight of Mean Appro Expresse ial behavi individual responses ximate d ors behaviors based on d behavior 𝟏 { × 𝟐𝟖}. Likert Mean 𝟏𝟎𝟎 scale 1. Making degrading comments 1 3.57 1.97 2 Present about other nurses 2. Sexually harassing other 1 3.57 3.39 3 Present nurses 3. Sexually harassing student 1 3.57 3.16 3 Present nurses 4. Using disrespectful language 1 3.57 2.84 3 Present to superiors 5. Intimidating each other 1 3.57 3.53 4 Absent 6. Refusal to work with other 1 3.57 2.65 3 Present nurses 7. Backbiting other nurses 1 3.57 2.05 2 Present 8. Verbal exchanges with other 1 3.57 2.63 3 Present nurses 9. Physical fight with other 1 3.57 3.50 4 Absent nurses in the hospital 10. Physical fight with other 1 3.57 3.60 4 Absent nurses outside the hospital 11. Senior nurses humiliating 1 3.57 2.30 2 Present subordinates in front of other nurses 12. Senior nurses humiliating 1 3.57 2.26 2 Present subordinates in-front of patients 13. Nurses bullying student 1 3.57 2.77 3 Present nurses on clinical duties 14. Do not complete all 1 3.57 1.43 1 Present procedures before leaving ward 15. Seniors humiliate 1 3.57 2.59 3 Present subordinates 16. Nurses discriminating 1 3.57 2.56 3 Present between patients 65 University of Ghana http://ugspace.ug.edu.gh 17. Nurses not happy with 1 3.57 2.54 3 Present profession 18. Nurses playing with phones 1 3.57 2.31 2 Present at the expense of patients 19. Making calls while attending 1 3.57 2.35 2 Present to patients 20. Refusing to attend to patients 1 3.57 3.03 3 Present 21. Demanding illegal fees 1 3.57 3.17 3 Present 22. Nurses sexually harassing 1 3.57 3.41 3 Present patients 23. Nurses pocketing hospital 1 3.57 3.32 3 Present monies 24. Drinking on duty 1 3.57 3.51 4 Absent 25. Drinking to duty 1 3.57 3.58 4 Absent 26. Not reporting on time 1 3.57 1.88 2 Present 27. Sleeping on duty 1 3.57 2.61 3 Present 28. Leaving ward before next 1 3.57 2.80 3 Present shift reports Total 28 100 Source: Study Data, (2017) The various disruptive behavior patterns that were tested among professional nurses in the private healthcare sector are shown in Table 4.12. 14 The various disruptive behavior patterns which were found to be present among nurses in the private sector are further outlined in Table 4.13. 1423(82.14%) of the disruptive behaviour patterns were exhibited by nurses in private institutions while only 5(17.86%) were not exhibited. 66 University of Ghana http://ugspace.ug.edu.gh Table 4.13 Disruptive behaviors exhibited by professional nurses in the private healthcare institutions in the Greater Accra Region, Ghana Serial Behavior Scrutinized 1 Making degrading comments about other nurses 2 Sexually harassing other nurses 3 Sexually harassing student nurses 4 Using disrespectful language to superiors 6 Refusal to work with other nurses 7 Backbiting other nurses 8 Verbal exchanges with other nurses 11 Senior nurses humiliating subordinates in front of other nurses 12 Senior nurses humiliating subordinates in front of patients 13 Nurses bullying student nurses on clinical duties 14 Do not completes all procedures before leaving ward 15 Seniors humiliate subordinates 16 Nurses discriminating between patients 17 Nurses not happy with profession 18 Nurses playing with phones at the expense of patients 19 Making calls while attending to patients 20 Refusing to attend to patients 21 Demanding illegal fees 22 Nurses sexually harassing patients 23 Nurses pocketing hospital monies 26 Not reporting on time 27 Sleeping on duty 28 Leaving ward before next shift reports Source: Study Data, (2017) Table 4.13 presents the various behavior patterns which were disruptively exhibited among nurses in the private healthcare institutions identified.15 15Out of the 23 disruptively exhibited behavior patterns which are listed in Table 4.13, 12(52.1%) of them are behaviors which nurses have suffered on the hands of other nurses 67 University of Ghana http://ugspace.ug.edu.gh 4.4.2 Identification of behavior patterns among professional nurses in public healthcare institutions in the Greater Accra Region, Ghana Using all prior assumptions, the responses to the various behavior patterns among nurses in the public healthcare institutions in the Greater Accra Region, Ghana were coded and analyzed based on the mean score for the responses to each item. A compilation of the disruptive behavior patterns exhibited by nurses in the public healthcare institutions together with their mean response rates and approximated mean are presented in Table 4.14. Table 4.14 Behavior patterns of nurses in public healthcare institutions Seri Behavior type No. of Weight of Mean Appr Expresse al behaviors individual respons oxima d behaviors e base ted behavior on mean Likert scale 1. Making degrading comments 1 3.57 2.4571 2 Present about other nurses 2. Sexually harassing other 1 3.57 3.7714 4 Absent nurses 3. Sexually harassing student 1 3.57 3.4952 3 Present nurses 4. Using disrespectful language 1 3.57 2.9619 3 Present to superiors 5. Intimidating each other 1 3.57 3.8381 4 Absent 6. Refusal to work with other 1 3.57 2.9905 3 Present nurses 7. Backbiting other nurses 1 3.57 2.2190 2 Present 8. Verbal exchanges with other 1 3.57 2.7429 3 Present nurses 9. Physical fight with other 1 3.57 3.7714 4 Absent nurses in the hospital 68 University of Ghana http://ugspace.ug.edu.gh 10. Physical fight with other 1 3.57 3.8667 4 Absent nurses outside the hospital 11. Senior nurses humiliating 1 3.57 2.5524 3 Present subordinates in front of other nurses 12. Senior nurses humiliating 1 3.57 2.6667 3 Present subordinates in front of patients 13. Nurses bullying student 1 3.57 3.5143 4 Absent nurses on clinical duties 14. Do not completes all 1 3.57 1.5143 2 Present procedures before leaving ward 15. Seniors humiliate 1 3.57 2.7619 3 Present subordinates 16. Nurses discriminating 1 3.57 3.1905 3 Present between patients 17. Nurses not happy with 1 3.57 2.7238 3 Present profession 18. Nurses playing with phones 1 3.57 2.3905 2 Present at the expense of patients 19. Making calls while attending 1 3.57 2.2762 2 Present to patients 20. Refusing to attend to patients 1 3.57 3.3143 3 Present 21. Demanding illegal fees 1 3.57 3.3714 3 Present 22. Nurses sexually harassing 1 3.57 3.8286 4 Absent patients 23. Nurses pocketing hospital 1 3.57 3.2952 3 Present monies 24. Drinking on duty 1 3.57 3.4000 3 Present 25. Drinking to duty 1 3.57 3.3143 3 Present 26. Not reporting on time 1 3.57 2.0190 2 Present 27. Sleeping on duty 1 3.57 2.8381 3 Present 28. Leaving ward before next 1 3.57 2.7810 3 Present shift reports Total 28 100 Source: Study Data, (2017) 69 University of Ghana http://ugspace.ug.edu.gh Table 4.14 presents the behavior patterns that were tested among nurses in public healthcare institutions together with their mean scores.16 Table 4.15 Disruptive Behaviors among professional nurses in the public healthcare institutions in the Greater Accra Region, Ghana. Serial Exhibited Behaviors 1. Making degrading comments about other nurses 3. Sexually harassing student nurses 4. Using disrespectful language to superiors 6 Refusal to work with other nurses 7 Backbiting other nurses 8 Verbal exchanges with other nurses 11 Senior nurses humiliating subordinates in front of other nurses 12 Senior nurses humiliating subordinates in front of patients 14 Do not completes all procedures before leaving ward 15 Seniors humiliate subordinates 16 Nurses discriminating between patients 17 Nurses not happy with profession 18 Nurses playing with phones at the expense of patients 19 Making calls while attending to patients 20 Refusing to attend to patients 21 Demanding illegal fees 23 Nurses pocketing hospital monies 24 Drinking on duty 25 Drinking to duty 26 Not reporting on time 27 Sleeping on duty 28 Leaving ward before next shift reports Source: Study Data, (2017) 16From the total of 28 behavioral patterns exhibited by nurses in the health sector, the study showed that 22(78.57%) of the disruptive behaviors were present among nurses as illustrated in table 4.14. (26.08%) of the disruptive behaviors were however absent. 70 University of Ghana http://ugspace.ug.edu.gh Table 4.15 outlines the various disruptive behavior patterns which were reported to be exhibited by nurses in the public healthcare institutions which were identified.1718 4.5 Comparison of disruptive behaviors among nurses in the private and public healthcare institutions in the Greater Accra Region, Ghana. Objective 2 of the study sought to compare the disruptive behaviors which are exhibited by nurses in the private and public healthcare institutions which were identified. Using all prior assumptions in categorizing behavior patterns as disruptive, this section seeks to compare the various behavior patterns among nurses in both institution types Table 4.16 Comparison of disruptive behavior among nurses in private and public healthcare institutions Variable Type of N Mean Standard Behavior Sector Deviation Type 1. Making degrading Private 105 1.97 .92463 Present comments about other Public 105 2.46 1.02871 Present nurses 2. Sexually harassing other Private 105 3.39 .98542 Present nurses Public 105 3.77 .60855 Absent 3. Sexually harassing Private 105 3.16 1.16126 Present student nurses Public 105 3.50 .90004 Absent 4. Using disrespectful Private 105 2.85 1.07221 Present language to superiors Public 105 2.96 1.03704 Present 5. Intimidating each other Private 105 3.53 .91006 Absent Public 105 3.84 .53930 Absent Private 105 2.66 1.08156 Present 17Out of the 22 disruptive behavior patterns which were identified, 10(45.45%) were observed to be behavior patterns which nurses suffer at the hands of other nurses. 186(21.43%) of the behavior patterns were absent among nurses in public healthcare institutions. 71 University of Ghana http://ugspace.ug.edu.gh 6. Refusal to work with Public 105 2.99 1.00475 Present other nurses 7. Backbiting other nurses Private 105 2.06 1.06363 Present Public 105 2.22 .99015 Present 8. Verbal exchanges with Private 105 2.64 .98179 Present other nurses Public 105 2.74 .89902 Present 9. Physical fight with other Private 105 3.51 .92116 Absent nurses in the hospital Public 105 3.77 .60855 Absent 10.Physical fight with other Private 105 .89330 Absent nurses outside the hospital 3.61 Public 105 3.89 .52011 Absent 11.Senior nurses Private 105 2.31 1.13615 Present humiliating subordinates in Public 105 2.55 1.10053 Present front of other nurses 12.Senior nurses Private 105 2.27 1.13736 Present humiliating subordinates Public 105 2.67 1.02532 Present infront of patients 13.Nurses bullying student Private 105 2.77 1.19500 Present nurses on clinical duties Public 105 3.16 1.02022 Present 14.Do not complete all Private 105 1.44 .81952 Present procedures before leaving Public 105 1.51 .86729 Present ward 15.Seniors humiliate Private 105 2.59 1.10676 Present subordinates in front of Public 105 2.76 .99541 Present health team 16.Nurses discriminating Private 105 2.56 1.12595 Present between patients Public 105 3.19 .98151 Present 17.Nurses not happy with Private 105 2.54 1.13535 Present profession Public 105 2.72 1.06062 Present 18.Nurses playing with Private 105 2.31 1.10344 Present phones at the expense of Public 105 2.39 .94559 Present patients 19.Making calls while Private 105 2.35 1.10924 Present attending to patients Public 105 2.28 .92503 Present 20.Refusing to attend to Private 105 3.04 1.08241 Present patients Public 105 3.31 .91267 Present 21.Demanding illegal Private 105 3.17 1.09595 Present fees Public 105 3.37 .97327 Present 22.Nurses sexually Private 105 3.42 1.02639 Present harassing patients Public 105 3.83 .61170 Absent 72 University of Ghana http://ugspace.ug.edu.gh 23.Nurses pocketing Private 105 3.32 1.01428 Present hospital monies Public 105 3.30 .96001 Present 24.Drinking on duty Private 105 3.50 .80997 Absent Public 105 3.40 .85034 Present 25.Drinking to duty Private 105 3.58 .75678 Absent Public 105 3.31 .92315 Present 26.Not reporting on time Private 105 1.89 .94375 Present Public 105 2.02 .82019 Present 27.Sleeping on duty Private 105 2.52 1.00092 Present Public 105 2.83 .94180 Present 28.Leaving ward before Private 105 2.80 1.12147 Present next shift reports Public 105 2.68 1.03306 Present Source: Study Data, (2017) Table 4.16 presents a compilation of all 28 disruptive behavior types which were examined in this study and a comparison of the manner in which each behavior is expressed in each type of healthcare institution (private and public). Table 4.17 Frequency of disruptive behaviors among nurses in private and public healthcare institutions Disruptive behavior Private Institutions Public Institutions Patterns tested Absent 5(17.86%) 6(21.43%) Present 23(82.14%) 22(78.57%) Total 28(100%) 28(100%) Source: Study Data, (2017) 73 University of Ghana http://ugspace.ug.edu.gh Table 4.17 presents the frequency with which each healthcare sector displayed disruptive behavior patterns. 19 The table shows that nurses in the private healthcare institutions identified were more disruptive as compared to the nurses in the public healthcare institutions. It also went on to show that nurses in the public healthcare institutions were better behaved as compared to nurses in the private healthcare institutions in the Greater Accra Region of Ghana. Table 4.18 Most disruptive healthcare sector Type of healthcare Most disruptive (out of 20 mutually institution disruptive behavior types) Private 17(85%) Public 3(15%) Total 20(100%) Source: Study Data, (2017) Table 4.18 presents the most disruptive category of healthcare institution.20 19Nurses in the private healthcare institutions did not exhibit 17.86% of the disruptive behaviors, while nurses in the public healthcare institutions were did not exhibit 21.43% of the disruptive behaviors. Nurses in the private healthcare institutions were also observed to be disruptive 82.14% of the time, as compared to 78.57% for nurses in the public healthcare institutions. 20The table shows that nurses in the private healthcare institutions were more disruptive in 17(85%) of the 20 disruptive behavior patterns mutually exhibited in both health sectors. Nurses in the public healthcare institutions identified on the other hand, were more disruptive in 3(15%) of the 20 disruptively exhibited behavior types. 74 University of Ghana http://ugspace.ug.edu.gh 4.6 Relationship between educational qualification of nurses and disruptive behavior patterns Objective three of this study was to determine the relationship(s) between educational qualification of nurses and their disruptive behavior patterns. A Spearman’s Rank Correlation test was conducted to determine the existence and nature of said relationships. Pallant (2006) indicates that Spearman’s Rank Correlation Coefficient (ρ) gives the strength and direction of a relationship. It ranges between -1 to +1 coefficient values. The Spearman’s Rank Correlation coefficients are indicated in Table 4.19. The negative correlation indicates that the high values on one variable are associated with low values on the next. A positive correlation indicates that high values on the one variable are associated with high values the next. Beyond these, Pallant, (2006) shows that correlations have different strengths; 0.00- 0.19 is an indication of a very weak relationship, 0.20 – 0.39 shows a weak relationship, 0.40-0.59 is indicative of a moderate relationship, 0.60-0.79 is indicative of a strong relationship, and 0.80-1.0 is indicative of a very strong relationship. However, the sign of the relationship does not indicate the strength as a (-).50 is the same strength as (+).50 but in different directions (Pallant, 2006). 75 University of Ghana http://ugspace.ug.edu.gh Table 4.19 Relationship between educational qualification of nurses and disruptive behavior patterns Disruptive behavior patterns df Spearman’s Correlation coefficient ρ Making degrading comments about other nurses 18 0.018 Sexually harassing other nurses 18 0.079 Sexually harassing student nurses 18 -0.020 Using disrespectful language to superiors 18 0.072 Intimidating other 18 0.054 Refusal to work with other nurses 18 0.097 Backbiting other nurses 18 -0.039 Verbal exchanges with other nurses 18 -0.108 Physical fight with other nurses in the hospital 18 -0.015 Physical fight with other nurses outside the 18 0.004 hospital Senior nurses humiliating subordinates in front of 18 0.018 other nurses Senior nurses humiliating subordinates in front of 18 0.103 patients Nurses bullying student nurses on clinical duties 18 0.187** Do not complete all procedures before leaving 18 0.007 ward Seniors humiliate subordinates 18 0.183** Nurses discriminating between patients 18 0.110 76 University of Ghana http://ugspace.ug.edu.gh Table 4.19 Continued Behavior patterns df Spearman’s Correlation coefficient ρ Nurses not happy with profession 18 0.209** Nurses playing with phones at the expense of 18 0.117 patients Making calls while attending to patients 18 0.075 Refusing to attend to patients 18 0.120 Demanding illegal fees 18 0.158* Nurses sexually harassing patients 18 0.120 Nurses pocketing hospital monies 18 0.101 Drinking on duty 18 -0.085 Drinking to duty 18 -0.142* Not reporting on time 18 -0.141* Sleeping on duty 18 0.060 Leaving ward before next shift reports 18 0.070 *Correlation is significant at 0.05 level 2 tailed ** Correlation is significant at 0.01 level 2 tailed Table 4.19 presents the Spearman Rank Correlation table depicting the relationship(s) between educational qualifications of nurses and their behavior patterns.21 21The table shows that there is a relationship between all 28 identified disruptive behavior patterns and educational qualification of nurses. It revealed a weak relationship between educational qualification of nurses and the behavior pattern of nurses not being happy with their profession (ρ=0.209). Further, the table shows that there are very weak relationships (0.00 ≤ ρ ≤ 0.19) between educational qualification and the remaining 27 behavior patterns 77 University of Ghana http://ugspace.ug.edu.gh 4.7 Testing of hypothesis The working hypothesis for this study was that “there is a significant difference is disruptive behaviors among nurses in private and public healthcare institutions in the Greater Accra Region, Ghana”. This hypothesis was tested for all the behavior patterns which were examined in the study. The hypothesis was tested using the Mann-Whitney U, to test for difference of the behavior patterns across the two categories of healthcare institutions. The Mann –Whitney U test is the non-parametric equivalent of the Independent T test. It is used to test for difference between the means of two independent samples; provided the responses are categorical and ordinal (Pallant, 2006). The Decision Rule for the hypothesis testing in Mann-Whitney U is: Reject Hο if Ս < α Where Ս is the Mann-Whitney U test statistic or the P value, and α = 0.05. The hypothesis test summary table is presented in Appendix 3. Results for each hypothesis are presented in the subsequent sections. 4.7.1 Nurses making degrading comments about other nurses Hο: The behavior pattern of nurses making degrading comments about other nurses is the same across public and private healthcare institutions From the Mann-Whitney U test, Ս=0.001 and since the p value (0.001) < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically significant difference in the behavior pattern of “nurses making degrading comments about 78 University of Ghana http://ugspace.ug.edu.gh other nurses” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.2 Nurses sexually harassing other nurses Hο: The behavior pattern of nurses sexually harassing other nurses is the same across public and private healthcare institutions From the Mann-Whitney U test, Ս=0.003 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically significant difference in the behavior pattern of “nurses sexually harassing other nurses” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.3 Nurses sexually harassing student nurses Hο: The behavior pattern of nurses sexually harassing student nurses is the same in private and public healthcare institutions From the Mann-Whitney U test, Ս=0.036 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude there is a statistically significant difference in the behavior pattern of “nurses sexually harassing student nurses” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.4 Nurses using disrespectful language to superiors Hο: The behavior pattern of nurses using disrespectful language to superiors is the same across private and public healthcare institutions 79 University of Ghana http://ugspace.ug.edu.gh From the Mann-Whitney U test, Ս=0.442 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude there is NO statistically significant difference in the behavior pattern of “nurses using disrespectful language to superiors” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.5 Nurses intimidating each other Hο: The behavior pattern of nurses intimidating each other is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.004 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically significant difference in the behavior pattern of “nurses intimidating each other” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.6 Nurses refusing to work with other nurses Hο: The behavior pattern of nurses refusing to work with other nurses is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.023 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically significant difference in the behavior pattern of “nurses refusing to work with other nurses” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.7 Nurses backbiting other nurses Hο: The behavior pattern of nurses backbiting other nurses is the same across private and public healthcare institutions 80 University of Ghana http://ugspace.ug.edu.gh From the Mann-Whitney U test, Ս=0.141 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of “nurses backbiting other nurses” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.8 Nurses having verbal exchanges with other nurses Hο: The behavior pattern of nurses having verbal exchanges with other nurses is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.448 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of “nurses having verbal exchanges with other nurses” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.9 Nurses having physical fights with other nurses in the hospital Hο: The behavior pattern of nurses having physical fights with other nurses in the hospital is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.021 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically significant difference in the behavior pattern of “nurses having physical fights with other nurses in the hospital” in private and public healthcare institutions in the Greater Accra Region of Ghana. 81 University of Ghana http://ugspace.ug.edu.gh 4.7.10 Nurses having physical fights with other nurses outside the hospital Hο: The behavior pattern of nurses having physical fights with other nurses outside the hospital is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.019 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically significant difference in the behavior pattern of “nurses having physical fights with other nurses outside the hospital” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.11 Senior nurses humiliating subordinates in front of other nurses Hο: The behavior pattern of senior nurses humiliating subordinates in front of other nurses is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.087 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern “senior nurses humiliating subordinates in front of other nurses” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.12 Senior nurses humiliating subordinates in front of patients Hο: The behavior pattern of senior nurses humiliating subordinates in front of patients is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.006 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically 82 University of Ghana http://ugspace.ug.edu.gh significant difference in the behavior pattern of “senior nurses humiliating subordinates in front of patients” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.13 Nurses bullying student nurses on clinical duties Hο: The behavior pattern of nurses bullying student nurses on clinical duties is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.024 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically significant difference in the behavior pattern of “nurses bullying student nurses on clinical duties” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.14 Nurses not completing all patient care procedures before leaving the ward Hο: The behavior pattern of nurses not completing all patient care procedures before leaving the ward is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.412 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of “nurses not completing all patient care procedures before leaving the ward” in private and public healthcare institutions in the Greater Accra Region of Ghana. 83 University of Ghana http://ugspace.ug.edu.gh 4.7.15 Senior nurses humiliating subordinates in front of other members of the health team Hο: The behavior pattern of senior nurses humiliating subordinates in front of other members of the healthcare team is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.252 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of “senior nurses humiliating subordinates in front of other members of the healthcare team” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.16 Nurses discriminating between patients Hο: The behavior pattern of nurses discriminating between patients is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.000 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically significant difference in the behavior pattern of “nurses discriminating between patients” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.17 Nurses not being happy with their profession Hο: The behavior pattern of nurses not being happy with their profession is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.217 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically 84 University of Ghana http://ugspace.ug.edu.gh significant difference in the behavior pattern of “nurses not being happy with their profession” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.18 Nurses playing with their phones at the expense of patients Hο: The behavior pattern of nurses playing with their phones at the expense of patients is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.374 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of “nurses playing with their phones at the expense of patients” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.19 Nurses making calls while attending to patients Hο: The behavior pattern of nurses making calls while attending to patients is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.826 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of “nurses making calls while attending to patients” in private and public healthcare institutions in the Greater Accra Region of Ghana. 85 University of Ghana http://ugspace.ug.edu.gh 4.7.20 Nurses refusing to attend to patients Hο: The behavior pattern of nurses refusing to attend to patients is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.076 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of “nurses refusing to attend to patients” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.21 Nurses demanding illegal fees Hο: The behavior pattern of nurses demanding illegal fees is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.210 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of “nurses demanding illegal fees” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.22 Nurses sexually harassing patients Hο: The behavior pattern of nurses sexually harassing patients is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.000 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically significant difference in the behavior pattern of “nurses sexually harassing patients” in private and public healthcare institutions in the Greater Accra Region of Ghana. 86 University of Ghana http://ugspace.ug.edu.gh 4.7.23 Nurses pocketing hospital monies Hο: The behavior pattern of nurses pocketing hospital monies is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.662 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of the behavior “nurses pocketing hospital monies” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.24 Nurses drinking on duty Hο: The behavior pattern of nurses drinking on duty is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.243 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern “nurses drinking on duty” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.25 Nurses being drunk on duty Hο: The behavior pattern of nurses being drunk on duty is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.024 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that there is a statistically significant difference in the behavior pattern of “nurses being drunk on duty” in private and public healthcare institutions in the Greater Accra Region of Ghana. 87 University of Ghana http://ugspace.ug.edu.gh 4.7.26 Nurses not reporting to work on time Hο: The behavior pattern of nurses not reporting to work on time is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.103 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of “nurses not reporting to work on time” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.27 Nurses sleeping on duty Hο: The behavior pattern of nurses sleeping on duty is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.038 and since p < α (0.05), we reject the null hypothesis at the 95% confidence interval and conclude that the behavior pattern of “nurses sleeping on duty” is not the same in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.7.28 Nurses leaving the ward before the next shift reports Hο: The behavior pattern of nurses leaving the ward before the next shift reports is the same across private and public healthcare institutions From the Mann-Whitney U test, Ս=0.548 and since p > α (0.05), we fail to reject the null hypothesis at the 95% confidence interval and conclude that there is NO statistically significant difference in the behavior pattern of “nurses leaving the ward before the next 88 University of Ghana http://ugspace.ug.edu.gh shift reports” in private and public healthcare institutions in the Greater Accra Region of Ghana. 4.8 Chapter summary This chapter presented the results from data analysis. The study aimed at comparing disruptive behaviors among nurses in private and public healthcare institutions. Using the Cross-sectional Survey approach and a 36 item close ended questionnaire developed by the Researcher using behavior patterns of nurses identified in literature. Findings were presented in the form of descriptive and inferential statistics. A total of 210 randomly selected nurses; 105 each from 2 public and 4 private healthcare institutions; formed the respondents for the study. None of the items on the questionnaire recorded missing values. The study revealed that majority of the 28 disruptive behavior patterns which were identified from literature and the pilot study are exhibited in healthcare institutions in the Greater Accra Region of Ghana. The study also discovered, using descriptive statistics, that in as much as nurses in both types of healthcare institutions were generally disruptive, nurses in Private healthcare institutions were more disruptive as compared nurses in public healthcare institutions. Further, using the Spearman’s Rank Correlation Test, the study revealed a relationship between educational qualification of nurses and all the 28 behavior patterns identified. Also, the study identified a positive correlation among 22(78.57%) of the disruptive behavior patterns indicating that the more educated a nurse is, the more disruptive they become. These correlations, even though generally very weak, are believed to be worth considering due to the delicate nature of the healthcare system. 89 University of Ghana http://ugspace.ug.edu.gh Finally, using the Mann-Whitney U test, the study tested hypotheses to determine whether there is a difference in assertive and disruptive behaviors exhibited by nurses in private and public healthcare institutions, Using the Mann-Whitney U, study revealed a statistically significant difference in 13 out of the 28 disruptive behavior patterns among nurses in private and public healthcare institutions in the Greater Accra Region of Ghana, while 15 of the behavior patterns revealed no statistically significant difference among nurses in both sectors of healthcare institutions. 90 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0 DISCUSSION OF FINDINGS 5.1 Introduction The previous chapter presented the findings of the study. This chapter presents a discussion of the various findings. Findings are discussed in relation to literature previously reviewed Chapter 2 of this study. The format for discussion is based on the various objectives and hypothesis developed for this study. The major objective of this study was to compare the disruptive behaviors among nurses in public and private healthcare institutions in the Greater Accra Region of Ghana. The study employed a Cross-sectional Survey approach using the Social Cognitive Theory and Model of Reciprocal Determinism. This approach was used because it expressed human behavior within organizations as a product of the organization’s environment, the individual’s personal and other behavioral factors, including observational learning. The working hypothesis for this study was that there is no statistically significant difference in disruptive behaviors among nurses in public and private healthcare institutions in the Greater Accra Region of Ghana. Hypothesis testing was done using the Mann Whitney U test. 5.2 Disruptive behaviors exhibited by professional nurses in private and public healthcare institutions in the Greater Accra Region of Ghana It has earlier on been established that nurse behavior is very crucial in every aspect of healthcare. This is because nurses are the single largest group of healthcare professionals and also, nurses are in closest proximity with the actual care rendered to patients, as 91 University of Ghana http://ugspace.ug.edu.gh compared to other categories of health workers. Amongst the behavior patterns which were earlier on stated as having been identified by Borkowski (2016), this current study also revealed that majority of those behavior patterns are exhibited by nurses in both sectors of healthcare institutions in the Greater Accra region of Ghana. Nurses in private healthcare institutions in the Greater Accra Region of Ghana were disruptive in 23 out of the 28 behavior patterns which were included in the questionnaire. These disruptively exhibited behavior patterns include nurses making degrading comments about other nurses, nurses sexually harassing other nurses, nurses sexually harassing student nurses, nurses pocketing hospital monies, not reporting to work on time, sleeping whiles on duty and leaving the ward before the next shift reports for duty. The remaining behavior patterns which were disruptively exhibited include nurses using disrespectful language to superiors, refusal to work with other nurses, backbiting other nurses, verbal exchanges with other nurses, senior nurses humiliating subordinates in front of other nurses, senior nurses humiliating subordinates in front of patients, bullying student nurses on clinical duties, not completing all procedures before leaving ward. Seniors humiliate subordinates, nurses discriminating between patients, nurses not happy with profession, nurses playing with phones at the expense of patients, making calls while attending to patients, refusing to attend to patients, demanding illegal fees, and nurses sexually harassing patients. 92 University of Ghana http://ugspace.ug.edu.gh These behaviors which have been identified in the study are also consistent with findings from Hader (2008), Rocker (2008) and Capitulo (2009) which named these behavior patterns among the list of behavior which are disruptively exhibited by nurses in healthcare institutions. These authors reported that the above listed disruptive behavior patterns are carried out and encountered by nurses in the course of discharging their duties. Further, these behaviour patterns are exhibited in varying severity in each healthcare institution. For nurses in the public healthcare institutions, this current study revealed that the disruptive behaviors which were exhibited in the public sector include nurses making degrading comments about other nurses, sexually harassing student nurses, using disrespectful language to superiors, refusal to work with other nurses, backbiting other nurses, having verbal exchanges with other nurses, senior nurses humiliating subordinates in front of other nurses, senior nurses humiliating subordinates in front of patients, not completing all procedures before leaving ward, seniors humiliate subordinates, discriminating between patients, nurses not happy with profession, playing with phones at the expense of patients, making calls while attending to patients, refusing to attend to patients, demanding illegal fees, nurses pocketing hospital monies, drinking on duty, drinking to duty, not reporting on time, sleeping on duty, and nurses leaving the ward before next shift reports for duty. The above listed behavior patterns which have been identified as being disruptively exhibited by nurses in private and public hospitals in the Greater Accra Region of Ghana 93 University of Ghana http://ugspace.ug.edu.gh respectively, are an indication of the severity of the presence of disruptive behaviors among nurses in our hospital settings. It goes to show that the menace of disruptive behaviors among nurses is deeply rooted in our healthcare institutions and supports the assertion by Longo (2010), Hader (2008) and the Department of Health and Human Services (2016) that disruptive behaviors among nurses have been long existent in the healthcare system, and that its longstanding presence has translated into such behaviors becoming subtly accepted as a part of the system. This, however, is rather unfortunate, considering the nature of the severity of detrimental effects which disruptive behaviors have on other nurses, patients, and other members of the healthcare team as outlines by the International Society of Psychiatric and Mental-Health Nurses (2014). Such effects have been identified as ranging from undermining the culture of safety, retention of nursing and other categories of healthcare staff, undermining nurses’ self confidence in caring for patients, undermining patients’ trust in their caregivers, and ultimately, undermining patient safety (Borkowski, 2016). The severity of the disruptive behavior patterns exhibited by nurses in both sectors of healthcare institutions could also be attributed to findings by Berman-Kishony & Shvarts (2015) which reported that many nurses who engaged in disruptive behavior are mostly unaware of their actions. They mostly do not think their actions have any negative effect of themselves, their colleague nurses and their patients. Therefore, in managing disruptive behavior among nurses, it is important to first of all make the offenders aware of such behaviors they may be exhibiting unknowingly, and also try to unravel the root cause of the problem. 94 University of Ghana http://ugspace.ug.edu.gh For the private healthcare institutions, this study revealed that out of the 23 disruptively exhibited behavior patterns which were identified, 12(52.1%) of them are behaviors which nurses have suffered on the hands of other nurses. This finding is consistent with Hader (2008), a survey which was conducted to determine the nature and extent of disruptive behaviors among nurses. Out of a sample size of nearly 1,400 registered nurses, nearly 80% reported witnessing a nursing colleague being subjected to violence in the work place and 50% reported having been victims of workplace violence themselves. Hader (2008) also revealed that nurses are subject to disruptive behavior mostly by patients (53.2% of the sample), followed by other nurses (51.9%). This finding is also consistent with assertions by Heqney et al., (2003), Hesketh et al, (2003) and Rowe & Sherlock (2005) which reported that disruptive behaviors among nurses are mostly reported as coming from their colleague nurses. For the public healthcare institutions however, out of the 22 disruptive behavior patterns which were identified, 10(45.45%) were observed to be behavior patterns which nurses suffer at the hands of other nurses. This goes to disprove findings by Hader (2008) who reported that majority of nurses who had been subject to disruptive behaviors suffered such behaviors at the hands of their fellow nurses more than half (51.9%) of the time. It also disproves findings from studies conducted by Heqney et al., (2003), Hesketh et al, (2003) and Rowe & Sherlock (2005) which reported that disruptive behaviors among nurses are mostly reported as coming from their colleague nurses. 95 University of Ghana http://ugspace.ug.edu.gh Finally, for both categories of healthcare institutions, this study revealed that the behavior pattern which was most disruptively exhibited amongst nurses was the fact that nurses did not complete all patient procedures before leaving duty. This particular behavior pattern recorded a mean score of 1.43 for private healthcare institutions and 1.51 for public healthcare institutions, making it the most disruptively exhibited behavior pattern among nurses in both sectors of healthcare institutions. Nursetogether.com (2012) has described this behavior pattern as a form of negligence in the nurse patient relationship, especially when the patient is in continuing need of the said patient care procedure. 5.3 Comparison of disruptive behaviors exhibited by professional nurses in private and public healthcare institutions in the Greater Accra Region of Ghana Objective two of this study sought to compare the various behavior patterns exhibited by nurses in public healthcare institutions, with those exhibited by nurses in private healthcare institutions in the Greater Accra Region of Ghana. Findings from this objective represent a section of organizational behavior among nurses which literature is extremely silent on. As a result, to a large extent, findings could not be compared to or contrasted with previously conducted research work. Findings are however discussed with regards to the mean scores of each behavior pattern, as stated in chapter 4 of this study. The study revealed that the behavior of nurses making degrading comments about other nurses is exhibited disruptively in both private and public healthcare institutions. However, this behavior is more disruptively exhibited among nurses in the private sector (1.97) as compared to nurses in the public sector (2.46). For the behavior type of nurses sexually harassing other nurses, the study revealed that nurses in the private health sector exhibit 96 University of Ghana http://ugspace.ug.edu.gh this behavior type in a disruptive manner (3.39) while nurses in the public healthcare institutions did not exhibit this behavior type (3.77). The third behavior pattern which was examined was nurses sexually harassing student nurses. The study revealed that nurses in the private healthcare institutions exhibit this behavior pattern in a disruptive manner (3.16), while nurses in the public healthcare institutions did not exhibit this type of behavior (3.50). Nurses using disrespectful language to their superiors was the fourth behavior pattern examined. It was revealed that nurses in both sectors exhibited this behavior pattern in a disruptive manner. The private sector recorded a mean response of 2.85 while the public sector had a mean of 2.96. Next was nurses’ intimidating each other. For this behavior pattern, both sectors of healthcare institutions reported that such actions were not exhibited by nurses. The private healthcare sector recorded a mean response of 3.53 and the public healthcare sector recorded a mean response of 3.84. The sixth behavior pattern was nurses refusing to work with other nurses. The study revealed that nurses in both the private and public sectors exhibited this behavior pattern disruptively. However, nurses in the private sector were more disruptive with a mean response of 2.66, while nurses in the public sector had a mean response of 2.99. With respect to the behavior pattern of nurses backbiting other nurses, the study revealed that nurses in both sectors exhibited the behavior pattern in a disruptive manner. Nurses in the 97 University of Ghana http://ugspace.ug.edu.gh private healthcare institutions were however more disruptive (2.06) as compared to nurses in the public healthcare institutions (2.22). Nurses having verbal exchanges with other nurses was observed to be exhibited disruptively among nurses in both sectors. Nurses in the private healthcare institutions recorded a mean response of 2.64 which shows that they are more disruptive when it comes to this behavior pattern, as compared to their colleagues in the public healthcare institutions who recorded a mean response of 2.74. Next was the behavior pattern of nurses having physical fights with other nurses in the hospital setting. Nurses in both sectors did not exhibit this behavior pattern. In a similar manner, nurses in both the private and public healthcare institutions did not exhibit the behavior pattern of nurses engaging in physical fights with other nurses outside of the hospital setting. This goes to say that nurses in both private and public healthcare institutions do not engage in physical fights with each other either within or outside the hospital. The next behavior pattern was senior nurses humiliating their subordinates in front of other nurses. The study revealed that nurses in both sectors are disruptive in this regard. This study however revealed that nurses in the private sector exhibited this behavior pattern in a more disruptive manner (2.31) as compared to nurse sin the public sector (2.55). Nurses in both the public and private healthcare institutions were observed to be disruptive with regards to senior nurses humiliating their subordinates in front of patients. Nurses in the 98 University of Ghana http://ugspace.ug.edu.gh private sector recorded a mean response of 2.27 and as such, are considered more disruptive in this regard, as compared to nurses in the public sector who had a mean response of 2.67. The study revealed that nurses in both the private and public healthcare institutions were disruptive with regards to nurses bullying student nurses on clinical duties. Table 4.16 however revealed that nurses in the private healthcare institutions were more disruptive (2.77) in this context as compared to their colleagues in the public healthcare institutions (3.16). The next behavior pattern which was examined is nurses not completing all patient care procedures before leaving ward. The study recorded nurses in both private and public healthcare institutions as disruptively exhibiting this behavior pattern. Private sector nurses were however more disruptive in this behavior (1.44) as compared to nurse sin the public sector (1.51). Nurses humiliating other nurses in front of other members of the health team was the next behavior pattern which was analyzed. The study revealed that nurses in both healthcare sectors were disruptive in this regard. However, nurses in the private healthcare institutions were more disruptive (2.59) as compared to nurses in the public healthcare institutions (2.76) This study revealed that nurses in both the private and public healthcare institutions identified disruptively exhibited the behavior pattern of nurses discriminating between patients. Nurses in the private sector were however more disruptive (2.56) than the nurses in the public sector (3.19). For the behavior pattern of nurses not being happy with their profession, the study revealed that nurses in both the private and public healthcare institutions exhibited this behavior pattern in a disruptive manner. Nurses in the private 99 University of Ghana http://ugspace.ug.edu.gh sector were however more disruptive with a mean response of 2.54 as against 2.7 for nurses in the public sector. For the behavior pattern of nurses playing with their phones at the expense of patient care, the study revealed that nurses in both sectors were disruptive, with nurses in the private sector being more disruptive (2.31) as compared to nurses in the public sector (2.39). The next behavior pattern which was examined was nurses making calls whiles attending to patients. Nurses in both the private and public sectors were both disruptive in this context. Nonetheless, nurses in the public sector were more disruptive, with a mean response of 2.28 as against 2.35 for nurses in the private sector. The next behavior patter was nurses refusing to attend to patients. The study revealed that nurses in both the public and private healthcare institutions exhibit this behavior pattern in a disruptive manner. Table 4.3.1 however shows that nurses in the private healthcare institutions were more disruptive (3.04) as compared to nurses in the public healthcare institutions (3.31). Next was nurses’ demanding of illegal fees from patients. The study showed that nurses in both sector exhibited this behavior pattern in a disruptive manner. Nurses in the private sector however had a mean response of 3.17, and as such, were more disruptive in this regard as compared to nurses in the public sector (3.37). For the behavior pattern of nurses sexually harassing patients, the study revealed that nurses in the private sector exhibited 100 University of Ghana http://ugspace.ug.edu.gh this behavior pattern in a disruptive manner, while nurses in the public sector did not practice this behavior. For the behavior pattern of nurses pocketing hospital monies, the study revealed that nurses from both sectors were disruptive in this regard. Nurses in the private sector were however more disruptive (3.32) as compared to nurses in the public sector (3.30). The behavior pattern of nurses drinking alcohol while on duty was analyzed next. Nurses in the private sector were observed not to exhibit this pattern of behavior, while nurses in the public sector exhibited disruptiveness with respect to this behavior pattern. The study showed that with regards to nurses being drunken whiles on duty, nurses in the private healthcare institutions did not practice this behavior, whiles nurses in the public healthcare institutions were found to practice this disruptive behavior. Next, was the behavior pattern of nurses not reporting to work on time. The study revealed that nurses in both the private and public healthcare institutions exhibited this behavior pattern in a disruptive manner. The study however revealed that nurses in the private healthcare institutions exhibited this behavior pattern in a more disruptive manner (1.89) as compared to nurses in the public healthcare institutions (2.02). Nurses’ sleeping on duty was the next behavior pattern which was analyzed. The study revealed that nurses in both healthcare sectors were disruptive with respect to this behavior pattern. Nurses in the private healthcare institutions were however observed to be more disruptive (2.52) as compared to nurses in the public healthcare institutions (2.83). The final behavior pattern 101 University of Ghana http://ugspace.ug.edu.gh which was analyzed was nurses leaving the ward before the next shift reports for duty. The study revealed that nurses in both healthcare sectors were disruptive in this regard. Nurses in the public healthcare institutions were however observed to me more disruptive (2.68) as compared to their colleagues in the private healthcare institutions. From the above comparison, the study revealed that nurses in the private healthcare institutions were disruptive 82.14% of the time, as compared to 78.57% for nurses in the public healthcare institutions. The study further revealed that out of the 28 identified behavior patterns, nurses in the private healthcare institutions were generally more disruptive as compared to nurses in the public healthcare institutions in the Greater Accra Region of Ghana. Further, out of the 28 behavior types which were identified, 20 of them were exhibited disruptively by both the private and public healthcare institutions. Out of these 20 mutually disruptively exhibited behavior types, the study revealed that nurses in the private healthcare institutions were more disruptive in 17(85%) of the behavior types. Nurses in the public healthcare institutions identified on the other hand, were more disruptive in 3(15%) of the 20 disruptively exhibited behavior types. This goes to say that nurses in the private healthcare institutions are more disruptive than their colleagues in the public healthcare institutions. This finding goes to disprove assertions made by Ojwang et al., (2013), that nurses in private healthcare institutions exhibit less disruptive organizational behavior as compared to their counterparts in the public sector. The author sought to attribute patient’s preference for private healthcare institutions over public institutions to the presumed disruptiveness on the part of public sector nurses. However, findings from this current study have suggested otherwise and as such, patient’s preference 102 University of Ghana http://ugspace.ug.edu.gh for private healthcare institutions over public ones may be as a result of other factors which need further investigation. The higher prevalence of disruptive behaviors among private sector nurses may be explained within the model of Reciprocal Determinism (Bandura, 1986). The model emphasizes the role of the environment in influencing individual behavior within an organization. In this context, the environments of both categories of institutions are said to influence nurse behavior. As has been discussed in Chapter 2 of this study. Public and private healthcare institutions may have different leadership styles, different physical environments, different working conditions, and different working hours, lighting and ventilation systems which all interact continuously to affect their behavior patterns (Mcartan, 2004; Arthur, 2012; Bartunek, 2011). With regards to working hours, nurses in private healthcare institutions are known to work for longer hours, as compared to nurses in public healthcare institutions (Bampoe, 2015). The effects of working for longer hours such as fatigue, lack of attentiveness and burnout among nurses could also account for the disruptive nature of private sector nurses as was reported by Berman-Kishony & Shvarts (2015), who found a significantly positive relationship between long working hours and disruptive behaviors in the hospital. Irrespective of the fact that private sector nurses were found to be more disruptive than public sector nurses, the study revealed disruptive behavior among nurses is high across both types of healthcare institutions. This is consistent with findings from Stecker et al., (2013), Jericho et al., (2010) that disruptive behaviors are very prevalent among healthcare 103 University of Ghana http://ugspace.ug.edu.gh workers, especially nurses, (since 87% of their sample were nurses). This finding also goes to empirically back public opinion documented by Ofosu-Kwarteng, (2012) that nurses in various healthcare institutions in Ghana are largely disruptive and Longo (2010)’s assertion that disruptive behaviors among nurses have long existed, however, little has been done in the bid to curb such behaviors and in effect, promote assertive behaviors among nurses (Longo, 2010). Farrell (2001) and Ford (2009) explained this trend as being as a result of oppression within the nursing profession. According to Farrell (2001), the oppression which nurses face in their day to day activities in the workplace results in displaced frustration which is then manifested as violence among co-workers. Weber (2004) also attributed this general disruptiveness across board among nurses in both categories of healthcare institutions as a result of the perceived superiority of physicians to nurses, which results in nursing creativity being undermined. Within the concept of Reciprocal Determinism is the concept of observational learning, which states that people can witness and observe and observe a behavior conducted by others, and then reproduce those actions (Bandura, 1986). Anderson (2012) explains the generally disruptive nature of nurses which has been reported by this current study as being as a result of nurses observing fellow nurses engaging in such as bullying and emotional abuse right from school. This, according to Afzali et al., (2015) is what results in the vicious cycle of disruptive behaviors among nurses. 104 University of Ghana http://ugspace.ug.edu.gh 5.4 Hypothesis testing The working hypothesis for this study was that there is no statistically significant difference in disruptive behaviors among nurses in public and private healthcare institutions in the Greater Accra Region of Ghana. This hypothesis was tested for all 28 behavior patterns. Findings revealed that for 15(53.57%) the manner in which nurses exhibited these behavior patterns were significantly different across both categories of healthcare institutions. These behavior patterns include nurses using disrespectful language to superiors, backbiting other nurses, having verbal exchanges with other nurses, humiliating subordinates in front of other nurses, not completing all procedures before leaving the ward, humiliating subordinates in front of other members of the healthcare team, not being happy with their profession, playing with phones at the expense of patient care, making calls whiles attending to patients, refusing to attend to patients, demanding illegal fees, pocketing hospital monies, drinking on duty, not reporting to work on time and nurses leaving the ward before the next shift reports for duty. Indicating that nurses in both sectors of healthcare institutions exhibit these behavior patterns in a similar manner and thus, similar remedies may be adopted to curb these behavior patterns in both categories of hospitals. On the other hand, the remaining 13 behavior patterns representing 46.43% were observed to be exhibited differently among nurses in private and public healthcare institutions. These behavior patterns include nurses making degrading comments about other nurses, sexually harassing other nurses, sexually harassing student nurses, intimidating each other, refusing to work with other nurses, having physical fights with other nurses in the hospital, having physical fights with other nurses outside the hospital, humiliating subordinates in front of patients, bullying student nurses on clinical duties, discriminating between patients, sexually harassing patients, and nurses sleeping on duty. Thus, in attempting to promote 105 University of Ghana http://ugspace.ug.edu.gh assertiveness and discourage disruptiveness among nurses, different approaches must be used with respect to these behavior patterns. It has earlier on been established that the sort of behavior exhibited by healthcare professionals is an important factor considered by patients when deciding on which category of healthcare institutions to patronize (Healthcare Domain, 2013). Ojwang, Ogutu, &Matu, (2013) have also reported that there is a general perception that nurses in private healthcare institutions exhibit better organizational behavior as compared to their counterparts in the public sector. Thus, if given the chance, and all other factors held constant, patients from various socio-economic backgrounds would rather prefer to patronize private healthcare institutions rather than public facilities Obuobi (1999). This study has however disproved this claim by revealing that contrary to general perception, nurses in private healthcare institutions are more disruptive in their behavior and public sector nurses are strangely rather assertive. Therefore, patients will, to a larger extent, experience the benefits of assertive nurse behavior (safer hospital environment, reduced incidents of medical errors, increased efficiency of nurses, and significantly better patient health outcomes) if the patronized public healthcare institutions as compared to private ones. 5.5 Relationship(s) between educational qualifications of nurses and their behavior patterns The third objective for this study was to determine the relationship(s), if any, between educational qualification of nurses and the behavior patterns which were identified. 106 University of Ghana http://ugspace.ug.edu.gh Spearman’s Rank Correlation coefficient was used to determine the existence of this relationship. It was further used to determine the nature of the relationship, if any. Nurses with higher educational qualifications have been assumed to be better equipped with information regarding the nature and effects of disruptive behavior and ways by which such behaviors can be combated (MacIntosh, 2006; Rosentein, 2002; Griffin, 2004). This current study revealed that there is a relationship between all 28 identified behavior patterns and educational qualification of nurses; keeping in mind that majority of these behavior patterns (71.43 %) were identified as being disruptively exhibited among nurses in both public and private healthcare institutions as indicated. That is to say that, there is a relationship between educational qualification of nurses and disruptive nurse behavior. The study went further to identify the nature of these relationships. It was revealed that educational qualification of nurses had a weak relationship (ρ=0.209) with the behavior pattern of nurses not being happy with their profession. Also there were very weak relationships (0.00 < ρ ≤ 0.19) between educational qualification and the remaining 27 behavior patterns. Notwithstanding the very weak relationships identified in almost all of the behavior patterns, the study revealed a negative correlation between educational qualification of nurses and six of the behavior patterns. These include “nurses sexually harassing student nurses” (ρ = -0.020), “nurses backbiting other nurses” (ρ = -0.039), “nurses having verbal exchanges with other nurses” (ρ = -0.108), “nurses having physical fights with other nurses within the hospital” (ρ = -0.015), “nurses drinking on duty” (ρ = -0.142) and “nurses not 107 University of Ghana http://ugspace.ug.edu.gh reporting to work on time” (ρ = -0.141). That goes to say that the higher the educational level of the nurse, the less likely they are to engage in these behavior patterns. As nurses rise on the educational ladder, they are less likely to sexually harass other nurses, backbite, have verbal exchanges with other nurses, engage in physical fights with other nurses within the hospital, drink on duty, and report to work late. This finding is in line with findings from Rosentein, (2002) and Griffin, (2004), which were of the view that the more educated a nurse is, the less disruptive they become. Irrespective of the negative correlation established between six of the behavior patterns, the study established a positive correlation among 22(78.57%) of the behavior patterns as illustrated in Table 4.4.1. These behavior patterns which have been expressed in their disruptive manner are an indication of increasing disruptiveness amongst nurses, whiles educational qualification also increased. According to this finding, as nurses become more educated, they become more disruptive, irrespective of the type of healthcare institution (Public or Private) they belong to. The reason behind this phenomenon could be the fact that junior nurses are generally more careful in their dealings with fellow nurses, patients, and other members of the health team. This is because junior nurses are more likely to face the full recourse of the law, in the event that they are caught engaging any nurse, patient, or any other member of the health team in a disruptive manner. It therefore goes to say that for disruptiveness amongst nurses to be curbed whiles promoting assertive behaviors, nurses must not be given the opportunity to upgrade themselves educationally. Few nurses, if any, must be allowed to further their education, so as to attain higher educational qualifications. The majority of nurses within any healthcare institution should consist of 108 University of Ghana http://ugspace.ug.edu.gh junior level nurses who, in this study, were observed to be generally less disruptive as compared to their senior colleagues. This finding contradicts findings from MacIntosh, (2006), Rosentein, (2002), and Griffin, (2004). According to these authors, since their findings revealed a positive relationship between educational levels and positive nurse behaviors, structures should be put in place to allow nurses to better educate themselves, in the hopes that they will adopt more assertive behavior patterns while dealing with their patients and other colleagues. Rosentein (2002) reported that providing nurses with the required incentives which allow them to educate themselves is a needed strategy curbing disruptive behaviors. According to him, increased educational levels provide nurses with the requisite knowledge to improve their working relationships with colleague nurses, patients, and other members of the health team. In the same vein, Griffin (2004) also asserted that newly qualified nurses who had received a high level of training on the use of cognitive techniques in dealing with disruptive behaviors are better able to deal with colleague nurses who displayed violence in the workplace. This current study has however reveled findings contrary to findings proposed by these authors. The positive relationship between educational qualification and disruptive behaviors among nurses is a relatively new finding which needs to be investigated further. Future research must attempt and replicating this study in a bid to see if similar results will be arrived at in different settings. Also, the reasons behind this positive relationship must be 109 University of Ghana http://ugspace.ug.edu.gh scientifically tested, so as to develop more efficient mechanisms in the fight of disruptive behaviors among nurses. Finally, future research must test the relationship between gender, age, number of years of service, number of promotions, and category of hospital against assertive and disruptive behaviors among nurses. 5.6 Chapter summary This chapter presented a discussion of findings for the study. Findings were, as much as possible, discussed in relation to existing literature in the field of organizational behavior in healthcare. However, the hypothesis testing could not be done in relation to literature due to little or no related research work conducted in the field of comparing nurse behaviors. This study has revealed that nurses in both sectors of the healthcare system are largely disruptive. This is evidenced by the fact that majority of the behavior patterns identified were disruptively exhibited by nurses in both categories of healthcare institutions. However, upon further investigation, the study revealed that nurses in the private healthcare institutions were generally more disruptive (85%) as compared to nurses in the public healthcare institutions (15%). Literature is however silent on this finding. Further, a positive relationship was identified between educational qualification and majority (78.57%) of the behavior patterns. 110 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX 6.0 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 6.1 Introduction Chapter five presented a discussion of the various findings derived from the study. This chapter presents the summary of the study; the various conclusions drawn from the findings and a suggestion of some recommendations which, in the researcher’s view, will help curb the menace of disruptive behaviors, whiles promoting assertive behaviors among nurses in private and public healthcare institutions in the Greater Accra region of Ghana. This chapter also presents a number of suggestions for future research. The comparison of disruptive behaviors among nurses in private and public healthcare institutions in the Greater Accra region of Ghana has been immensely educative and insightful. It has exposed the extent to which disruptive behaviors is prevalent among nurses, especially in the private healthcare institutions. It is hoped that findings from this study will be efficiently considered and recommendations implemented, so as to effectively manage the occurrence of disruptive behaviors among nurses. 6.2 Summary of the study Behavior among nursing staff is an important contributing factor to the entire healthcare process, especially to patients’ hospital experiences and patient health outcomes. Growing global health concerns have placed disruptive behaviors among nurses in the spotlight, making it a center of attention for various research projects. The Ghana Health Service Code of Conduct and Disciplinary Procedures together with the Ghana Health Service Code of Ethics and The Patients’ Charter, provide certain legal backings which seek to help 111 University of Ghana http://ugspace.ug.edu.gh keep nurses and other health workers in check so as to promote assertive behaviors in the healthcare setting. However, despite the presence of these regulations, nurses continue to act in unacceptable manners, sometimes, even to the knowledge of their healthcare managers. Consequentially, disruptive behaviors among nurses continue to linger on in our healthcare facilities, and are gradually becoming accepted by our health workers and patients alike as an everyday occurrence, and as such, behaviors which are otherwise unacceptable, have become the status quo. The manner in which a nurse conducts him/herself has a direct bearing on the patient. This is so because nurses are the single group of healthcare providers who are in prolonged and direct proximity to patients during healthcare delivery. This study was conducted to determine the various disruptive behavior patterns exhibited by nurses in selected private and public healthcare institutions in the Greater Accra Region of Ghana, compare the various disruptive behavior patterns, and also to determine the relationship between educational qualification of nurses and these disruptive behavior patterns. The study did so by employing the Cross-Sectional Survey design, which allowed for comparison of two or more variables at the same time. Using the Positivists Research Paradigm, a 36 item closed ended questionnaire which was developed using the Researcher’s own construct was administered to a sample size of 210 randomly selected nurses from a total of two public and four private purposively identified healthcare institutions in the Greater Accra Region of Ghana. Data collection recorded a response rate of 100% and responses recorded no missing values, due to the self-administered nature of data collection. The Statistical package for social Sciences (version 20) was used in generating descriptive and inferential 112 University of Ghana http://ugspace.ug.edu.gh statistics for data analyzed. The findings of the study were then discussed in relation to the literature that currently exists on disruptive behaviors among nurses. 6.3 Conclusions Findings from the first objective of the study revealed that nurses in the private healthcare institutions investigated exhibited 23(82.4%) of the 28 disruptive behavior patterns which were identified and tested, while nurses in the public healthcare institutions exhibited 22(78.57%). These behavior patterns which were exhibited range from nurses making degrading comments about other nurses to nurses leaving the ward before he next shift reports on duty. This finding was further analyzed in objective two which sought to establish which category of healthcare institutions was more disruptive. Objective two of this study revealed that contrary to the ideal practice, nurses in both private and public healthcare institutions in the Greater Accra Region of Ghana are largely disruptive, with nurses in the private healthcare institutions being more disruptive. This finding is worrying, because disruptiveness on the part of nurses results in a wide array of negative outcomes which threaten the safety and wellbeing of patients, nurses, and other members of the health team. This finding could partly be as a result longer working hours in private healthcare institutions, leadership styles of private healthcare managers, and the working environment of private these institutions. It may also be attributed to the fact that the private healthcare sector in the Greater Accra Region of Ghana remains highly unregulated. This was evidenced by some challenges which were encountered during the 113 University of Ghana http://ugspace.ug.edu.gh conduct of this study relating to acquiring the actual population of nurses working in private hospitals in the Greater Accra Region. Private healthcare institutions are either owned by for-profit companies or individuals, or not-for-profit organizations. The four private hospitals identified by this study, however, are all owned by for-profit individuals. That goes to say that these hospitals, in as much as they exist to provide optimum healthcare to their clients, are also very much interested in profit making, and as such, services provided are relatively more expensive, and are paid for by patients themselves or private insurance schemes. For patients who are paying higher fees for relatively similar services which are equally offered in some public healthcare institutions, the assumption is that nurses in private hospitals will exhibit the highest level of assertion as compared to their colleagues in the public hospitals, so as to provide their patients with the highest level of comfort and confidence in the healthcare system. This study has however proved that the opposite is the reality on the ground. Nurses in the private healthcare institutions were reported to sexually harass other nurses, demand illegal fees from patients, and sexually harass patients among other disruptive behaviors. They were observed to be generally disruptive in in twenty-three out of the twenty-eight identified behavior patterns and further identified to be more disruptive in seventeen of the twenty behavior patterns in which both sectors were disruptive. Still on objective two, in as much as nurses in the private healthcare institutions were revealed to be more disruptive than their counterparts in the public healthcare institutions, 114 University of Ghana http://ugspace.ug.edu.gh the study showed that nurses in the public healthcare institutions were also significantly disruptive. The difference in disruptiveness between the private and public sector nurses was small (3.57%), and as such, even though comparatively, the private sector nurses were more disruptive, the public sector nurses were also very much disruptive. They exhibited disruptiveness in twenty-two out of the twenty-eight expressed behavior patterns, and as such nurses in the public healthcare institutions equally require urgent intervention in order to subdue any imminent compromise to staff and patient safety. This finding has serious implications in the sense that nurses who are supposed behave in a professionally correct manner in order to aid patients in recovering quickly, are rather behaving in a largely disruptive manner. This could result in impaired nurse-patient relationships, medical errors on the part of nurses, suboptimal patient health outcomes, increased length of patient stay in the hospital setting, increased turnover among nurses and other members of the healthcare team and many more adverse effects. There is, thus, the urgent need for structures to be put in place which will minimize or curb the prevalence of disruptive behaviors among nurses and in effect, promote assertiveness among nurses. These are discussed in the recommendations section of this chapter. Objective three of this study sought to identify the relationship(s), if any, between educational qualification of nurses and the 28 behavior patterns which were identified. Findings from this objective revealed that there is an association between all the 28 identified disruptive behavior patterns and educational qualification of nurses. That goes to say that the behavior patterns exhibited by nurses are dependent on their educational qualification, and such, in order to modify nurse behavior, careful attention must be paid 115 University of Ghana http://ugspace.ug.edu.gh to their educational needs. Further tests were conducted to determine the nature of this association between educational qualification of nurses and the afore identified behavior patterns. The study further revealed a weak relationship between educational qualification of nurses and all 28 behavior patterns (very weak relationships with 27 of the behavior patterns and a weak relationship with 1 behavior pattern). Further, a negative correlation was identified between educational qualification and majority (78.57%) of the behavior patterns, which had been stated in the disruptive manner. Implications of these findings are that nurses with higher educational qualifications are generally more disruptive and as such, in order to minimize disruptiveness among nurses and promote assertiveness in any health facility, nurses with lower educational qualifications must form the majority of the nursing staff. Also, nurses must not be provided with opportunities to acquire higher educational qualifications. This finding generally goes contrary to existing literature and as such, must form the basis for further research. For 13 of the behavior patterns expressed, the study revealed through hypothesis testing that there were statistically significant differences in disruptive behaviors among nurses in private and public healthcare institutions in the Greater Accra Region of Ghana. For 15 of the behavior patterns however, the study revealed there were no statistically significant differences in disruptive behaviors indicating that for these behavior patterns, nurses in both categories of hospitals behave in a similar manner. That goes to say that more often 116 University of Ghana http://ugspace.ug.edu.gh than not, nurses in both private and public healthcare institutions in the Greater Accra region of Ghana exhibit disruptive behaviors in a similar manner as such, to a larger extent, similar remedies may be adopted in the bid to curb disruptive behaviors whiles promoting assertive behaviors among nurses. 6.4 Recommendations Based on the findings of the study, the following recommendations have been made with the hopes of curbing disruptive behaviors and promoting assertive behaviors among nurses in private and public healthcare institutions in the Greater Accra Region of Ghana. The study recommends that changes be made in the curricula for nursing training in order to help curb the occurrence of disruptive behaviors among nurses. It is suggested that disruptive behaviors among nurses must be included in the curricula for the various levels of nursing education, so as to well equip trainee nurses for their future practice. Also, disruptive behaviors among nurses must be a priority on the agenda at all levels of the nursing profession; from policy making at the national level to practice at facility level. Structured policies on management of both behavior patterns must be put in place so as to give legal backing to the management of the menace of disruptive behaviors among nurses. Further, resources must be allocated towards the implementation of such policies. A conscious effort must also be made in order to reflect such policies at the ward level so as to make implementation a success. 117 University of Ghana http://ugspace.ug.edu.gh Further, a structured program for periodic in-service training of nurse managers and all nursing staff on promoting assertive behaviors and curbing disruptive behaviors must be developed by the various Regional Health Directorates and passed on to all facilities. This will aid nurse to frequently update their knowledge on the nature and management of such behavior patterns. These training sessions must however be made accessible to nurses in both private and public healthcare institutions. The various Regional Health Directorates together with the Private Hospitals and Maternity Homes Board must periodically recognize and award healthcare facilities whose nurses are recorded to be most assertive within a period. Also, at the facility level, award and recognition schemes must be put in place for most assertive nurse of the month or any other duration deemed fit by hospital management. This is to serve as an incentive for assertive nurses and to encourage other nurses to follow suite. Further, coaching and mentoring programs must be implemented by the In-Service Training units of the various facilities to assist nurses who are consistently observed to be disruptive. When all these measures fail, effective punishments must be put in place and effectively carried out to nurses who are constantly observed to be disruptive in their dealings. Such punishments should be effectively meted out irrespective of rank, ace religion or any other consideration, so as to deter other nurses from engaging in disruptive behaviors. Lastly, the study identified a number of challenges with private healthcare institutions in the Greater Accra Region of Ghana. Topmost of these challenges was the unavailability of concrete data regarding the total number of nurses practicing in private hospitals in the 118 University of Ghana http://ugspace.ug.edu.gh region, indicating the unregulated (or sub optimally regulated) nature of private hospital practice in the region. The Private Hospitals and Maternity Homes Board must strengthen their regulation of the private healthcare institutions so as to improve quality of service and also to reduce the incidence of disruptive behaviors among nurses. 6.5 Suggestions for future research This study has revealed a number of issues which need to be addressed in the field of Organizational Behavior in Healthcare, specifically, among nurses. These include: 1. This study revealed a higher prevalence of disruptive behaviors among nurses in the private healthcare institutions as compared to nurses in public healthcare institutions. Future research must investigate the reasons for which this phenomenon is so. 2. This study compared the various behavior patterns of nurses from the perspective of the nurse. It is believed that a well-designed study must be conducted to compare the same behavior patterns among nurses from the patients’ perspective. 3. The positive relationship between educational qualification and disruptive behaviors among nurses is a relatively new finding which needs to be investigated further. Future research must be designed to scientifically determine the reason(s) behind this positive relationship, so as to develop more effective mechanisms in the fight of disruptive behaviors among nurses. 119 University of Ghana http://ugspace.ug.edu.gh References Adinkrah, J. M. (2014, February 12). Healthcare System in Ghana-Problems and Ways Forward. Retrieved November 17, 2016, from www.globalhealthstudents.sites.ku Afzali, M., Mokhtari, N. J., Ebadi, A., Khademolhosenyni, S. M., & Rejeh, N. (2015). 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Retrieved November 18, 2016, from https://www.travelnursing.com/news/nurse- news/nurses-compassionate-care-affects-patient-outcomes/ 127 University of Ghana http://ugspace.ug.edu.gh World Bank. (2007). The World Bank Strategy for HNP Results. World Bank. World Health Organization. (2007). Everybody's Business; Strengthening Health Systems To Improve Health Outcomes. WHO. Yousaf, A. (2015). Introduction to organiational Behavior. Retrieved September 11, 2016, from Slideplayer Web Site: http://slideplayer.com/slide/10996809/ 128 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix A: Introductory letter to identified healthcare institutions 129 University of Ghana http://ugspace.ug.edu.gh Appendix B: Research questionnaire QUESTIONNAIRE ON DISRUPTIVE NURSE BEHAVIORS I am a final year M.Phil. Health Services Management student of the University of Ghana Business School. I am conducting a survey on disruptive behaviors among nurses in public and private healthcare institutions in the Greater Accra Region of Ghana. I should be grateful if you could respond to the under listed questions to facilitate the research work. Your anonymity is greatly assured. Thank you very much in anticipation of your response for this academic exercise, please. SECTION A DEMOGRAPHY Please tick only one response ach to a question 1. Gender a) male b) female 2. Age group a) 18-25years b) 26-33years c) 34-41years d) 42-49 years e)50-57 years d) 58years and above 3. What is your nursing qualification? a) Doctorate b) Masters c) BSc d) BA e) Advanced Diploma f) Diploma g) Certificate 4. Which type of hospital do you work in? a) private b) public 5. How long have you practiced as a nurse? a) less than two years b) 2-5years c) 5-10years d) 10-15 years e) above 15-25 years f) above 25 years 6. How many times have you been promoted as a nurse? a) More than three times b) Three times c) Twice d) Once e) Never 7. Which type of hospital have you worked at before joining your current hospital? a) Private b) Public c) Not applicable 8. What category of nurses do you belong to? a) General nurse b) Mental nurse c) Community health nurse d) Midwife 130 University of Ghana http://ugspace.ug.edu.gh SECTION B NURSE TO NURSE BEHAVIORS Please tick only one response to each question Alway Someti Once Neve s mes r Description of behavior (More than once) 9. I have witnessed fellow nurses make degrading comments about other nurses 10. I have witnessed fellow nurses sexually harassing other nurses 11. I have witnessed fellow nurses sexually harassing student nurses 12. I have witnessed fellow nurses using disrespectful language in the workplace to superiors nurses 13. I have witnessed fellow nurses intimidating each other in the hospital 14. I have witnessed fellow nurses refuse to work with other nurses 15. I have witnessed fellow nurses backbiting other nurses 16. I have seen colleague nurses engage in verbal exchanges with other nurses 17. I have witnessed fellow nurses engage in physical fight with other nurses in the hospital 18. I have witnessed fellow nurses engage in physical fight outside the hospital with other nurses while in uniform 19. I have witnessed senior nurses humiliate their subordinates in front of other nurses 20. I have witnessed senior nurses humiliate their subordinates nurses in front of patients 21. I have witnessed fellow nurses bullying student nurses on clinical duties 131 University of Ghana http://ugspace.ug.edu.gh SECTION C NURSE TO PATIENT BEHAVIORS Please tick only one response to each question Someti mes Alway Onc Nev Description of behavior (More s e er than once) 22. I do not complete all patient care procedures before leaving the ward 23. I have witnessed senior nurses humiliate their subordinates in front of other members of the health team 24. I have witnessed nurses discriminate between patients they attend to because of monetary gains 25. I have seen nurses who are not happy with their profession 26. I have witnessed fellow nurses playing with their phones at the expense of patient care 27. I have witnessed fellow nurses respond to private phone calls while attending to patients 28. I have witnessed fellow nurses refusing to attend to patients 29. I have witnessed fellow nurses demand illegal fees from patients 30. I have witnessed fellow nurses sexually harassing patients 132 University of Ghana http://ugspace.ug.edu.gh SECTION D OTHER BEHAVIORS Someti mes Alway Onc Nev Description of behavior (More s e er than once) 31. I have witnessed fellow nurses pocket monies meant to be paid into the hospital coffers 32. I have witnessed fellow nurses being drunk on duty 33. I have witnessed fellow nurses consume alcohol before reporting for duty 34. I have witnessed fellow nurses not reporting to work on time 35. I have witnessed fellow nurses sleeping whiles on duty 36. `I have witnessed fellow nurses leave the ward whiles the next shift has not reported THANK YOU FOR TAKING PART IN THE SURVEY! 133 University of Ghana http://ugspace.ug.edu.gh Appendix C: Hypothesis test summary for Mann-Whitney U test Serial Null hypothesis Test Sig. Decision 1. The distribution of Making degrading Independent .00 Reject the null comments about other nurses is the same samples Mann- 1 hypothesis across categories of Type of hospital Whitney U test 2 The distribution of Sexually harassing Independent .00 Reject the null other nurses is the same across categories samples Mann- 3 hypothesis of Type of hospital Whitney U test 3 The distribution of Sexually harassing Independent .03 Reject the null student nurses is the same across samples Mann- 6 hypothesis categories of Type of hospital Whitney U test 4. The distribution of Using disrespectful Independent .44 Retain the null language to superiors is the same across samples Mann- 2 hypothesis categories of Type of hospital Whitney U test 5. The distribution of Intimidatingeach other Independent .00 Reject the null is the same across categories of Type of samples Mann- 4 hypothesis hospital Whitney U test 6. The distribution of Refusal to work with Independent .02 Reject the null other nurses is the same across categories samples Mann- 3 hypothesis of Type of hospital Whitney U test 7. The distribution of Backbiting other Independent .14 Retain the null nurses is the same across categories of samples Mann- 1 hypothesis Type of hospital Whitney U test 8. The distribution of Verbal exchanges Independent .44 Retain the null with other nurses is the same across samples Mann- 8 hypothesis categories of Type of hospital Whitney U test 9. The distribution of Physical fights with Independent .02 Reject the null other nurses in the hospital is the same samples Mann- 1 hypothesis across categories of Type of hospital Whitney U test 10. The distribution of Physical fights with Independent .01 Reject the null other nurses outside the hospital is the samples Mann- 9 hypothesis same across categories of Type of hospital Whitney U test 11. The distribution of Senior nurses Independent .08 Retain the null humiliating subordinates in front of other samples Mann- 7 hypothesis nurses is the same across categories of Whitney U test Type of hospital 12. The distribution of Senior nurses Independent .00 Reject the null humiliating subordinates in front of samples Mann- 6 hypothesis patients is the same across categories of Whitney U test Type of hospital 13. The distribution of Nurses bullying Independent .02 Reject the null student nurses on clinical duties is the samples Mann- 4 hypothesis same across categories of Type of hospital Whitney U test 134 University of Ghana http://ugspace.ug.edu.gh 14. The distribution of Not completing all Independent .41 Retain the null procedures before leaving the ward is the samples Mann- 2 hypothesis same across categories of Type of hospital Whitney U test 15. The distribution of Senior nurses Independent .25 Retain the null humiliating subordinates in front of other samples Mann- 2 hypothesis members of the health team is the same Whitney U test across categories of Type of hospital 16. The distribution of Nurses discriminating Independent .00 Reject the null between patients is the same across samples Mann- 0 hypothesis categories of Type of hospital Whitney U test 17. The distribution of Nurses not happy with Independent .21 Retain the null their profession is the same across samples Mann- 7 hypothesis categories of Type of hospital Whitney U test 18. The distribution of Nurses playing with Independent .37 Retain the null phones at the expense of patients is the samples Mann- 4 hypothesis same across categories of Type of hospital Whitney U test 19. The distribution of Nurses making calls Independent .82 Retain the null while attending to patients is the same samples Mann- 6 hypothesis across categories of Type of hospital Whitney U test 20. The distribution of Refusing to attend to Independent .07 Retain the null patients is the same across categories of samples Mann- 6 hypothesis Type of hospital Whitney U test 21. The distribution of Demanding illegal fees Independent .21 Retain the null is the same across categories of Type of samples Mann- 0 hypothesis hospital Whitney U test 22. The distribution of Nurses sexually Independent .00 Reject the null harassing patients is the same across samples Mann- 0 hypothesis categories of Type of hospital Whitney U test 23. The distribution of Nurses pocketing Independent .66 Retain the null hospital monies is the same across samples Mann- 2 hypothesis categories of Type of hospital Whitney U test 24. The distribution of Drinking on duty is the Independent .24 Retain the null same across categories of Type of hospital samples Mann- 3 hypothesis Whitney U test 25. The distribution of Being drunk on duty Independent .02 Reject the null is the same across categories of Type of samples Mann- 4 hypothesis hospital Whitney U test 26. The distribution of Not reporting to work Independent .10 Retain the null to time is the same across categories of samples Mann- 3 hypothesis Type of hospital Whitney U test 27. The distribution of Sleeping on duty is the Independent .03 Reject the null same across categories of Type of hospital samples Mann- 8 hypothesis Whitney U test 28. The distribution of Leaving the ward Independent .54 Retain the null before the next shift reports is the same samples Mann- 8 hypothesis across categories of Type of hospital Whitney U test 135 University of Ghana http://ugspace.ug.edu.gh 136