If nurse bullying is such a problem, why aren’t nurses talking more about it with each other?
According to Dr. Renee Thompson, DNP, RN, CMSRN, and CEO and president of RT Connections, LLC, and author of “Do No Harm” Applies to Nurses, Too!, most nurses don’t openly discuss bullying in the workplace because of some really basic reasons.
“We don’t talk about it because we are afraid,” she says. “We don’t talk about it because of the fear of retaliation, because we fear we might get terminated, and because we don’t know what to say.” And while nurses want to hear they won’t lose their jobs or they won’t get the worst assignments if they speak up, in reality, those very things could happen.
Nurse bullying isn’t new, says Dr. Thompson, although it seems to be getting worse. And while nurse bullying is a hot topic in the industry, it pops up in the media sometimes. Why? Well, the public has a hard time digesting the topic and they don’t want to think the nurses taking care of them could be tormenting each other. “A lot of people are shocked that nurses who are so caring and compassionate to their patients can be so horrible to each other,” says Dr. Thompson.
But if bullying isn’t halted, what happens? The industry feels the effects already, says Dr. Thompson. “Sixty percent of new nurses quit their first job within the first six months because of bullying behavior,” she says. “Forty eight percent of graduating nurses are afraid they will become the target of bullying.”
Just like the nursing profession, the roots of nurse bullying are complex, says Dr. Thompson.
Part of the problem, she says, is competitive nature that turns negative. “Instead of celebrating others’ accomplishments, we are thinking of ways to downplay or sabotage,” says Dr. Thompson. That means a promotion for a nurse could make other nurses turn on her.
And there’s plain old jealousy and envy. Lots of nurses, says Dr. Thompson, won’t even tell colleagues when they are going back to school. In fact, she says, some even forgo tuition assistance from work to keep it under wraps. Their ambition can make them a target of bullying behaviors.
And nurses are under increasing pressure at work, making an atmosphere that can turn tense. “Nurses are being asked to do more with less,” says Thompson. If they don’t have effective coping skills, some nurses can lash out at others.
Nurses have been tagged with the unfortunate label of “nurses eat their young,” but Dr. Thompson says that’s not always the case. She hears frequently from older nurses who are targets because of their age, because they aren’t as adept with technology, and because younger nurses see them as out of date. “This is the first time we have four generations in the same workplace,” says Dr. Thompson. “Now we are seeing bullying across all generations.”
Nurses who are different from the norm might find more bullying as well, says Dr. Thompson. She remembers being a new nurse and overhearing some of the older women complaining about a new young male nurse. “One said, ‘I don’t think men should be nurses, and I will do everything I can to make sure he doesn’t last here,’” recalls Dr. Thompson. So although men aren’t immune to the bullying among nurses, Dr. Thompson says they tend to react in a different manner. Men, she says, will often address the behavior immediately where many women won’t.
The cause of nurse bullying has many layers, and few of them are easy to navigate. Knowing the causes, being alert to behaviors, and talking with other nurses about bullying can help halt the problem in the long run.
Congratulations! You’ve managed to graduate from nursing school and pass the NCLEX-RN exam. In addition to that, you have successfully obtained a new-grad RN position after submitting thousands of applications. You’re now gainfully employed and about to embark on your new journey as a registered nurse. You’re very elated and excited to embark on this journey—and you deserve it. You have worked very hard to get here. However, that elation and excitement is short-lived due to the fact that you’re a new registered nurse, and as the saying goes, nurses eat their young.
Bullying towards new nurses isn’t new, and it’s a major problem. There have been many documented occurrences of new-grad bullying, but it’s not alleviating the problem. Unfortunately, this action is accepted and often swept underneath the rug. It’s as if the field of nursing is a sorority and new grads have to undergo a pledging process. It’s not enough that you’ve battled the trenches of nursing school and proven yourself to be a safe and sufficient nurse via passing boards. Now, you have to undergo the brutality and wrath of a negative, experienced nurse who sees you as an annoyance and, at times, a threat.
During my second week of orientation as a registered nurse, I was told by one of the nurse supervisors to watch my back because the experienced nurses could be “vengeful” at times. Her saying this to me was shocking for two reasons: 1) I couldn’t believe she acknowledged the fact that being vengeful towards a fellow nurse was happening on the unit. 2) As a nurse manager, wouldn’t you want to put an end to this behavior happening on your unit in order to maintain peace and order for the sake of patient safety?
Sad to say, this is a game, and new-grad RNs need to know how to play it. I come from a long line of nurses in my family, and when I spoke to them about this situation, they acknowledged that it happens and that I need to take special precautions to protect myself. Here are 10 tips to deal with new-nurse drama that they shared with me:
• Keep a journal and document your days at work. In this journal, keep a record of the date and time of specific events. This way, if you’re ever called into a meeting and/or you’re challenged concerning a situation, you will have a personal record of what was said and done.
• Come to work early and give yourself enough time to get organized. Being organized is key to nursing—and when you’re a new nurse, your coworkers are going to try to find any reason to be negative towards you. Being early and organized helps to alleviate this.
• Maintain a locker with a lock on it. It’s really unfortunate, but your coworkers could be the kind of people who would be “vengeful” and try to steal your items or tamper with your equipment.
• Don’t share any personal information. If you’re talkative like I am, this might be hard to do, but do it. You’re there to work, not to become best friends with anyone. Gaining friendships is fine, but your main priorities should be to protect your patients and yourself.
• Don’t be afraid to speak up and defend yourself. Often, new-grad RNs are made to feel inferior and fear speaking up due to retaliation. Don’t feel that way. You have a right to speak up and defend yourself, especially if you’re being threatened. Legally, you can’t get fired for that. Additionally, you can’t change whatever you tolerate. Therefore, you should acknowledge you deserve respect by standing up for yourself.
• Don’t do anything that is uncomfortable and/or wrong. During my orientation, one of the experienced nurses wanted me to help her distribute medications because she was late. She didn’t want me to look at the Medication Administration Record or any other vital information about the patient. Instead, she wanted to hand me the medications and give them to her patients. I told her no because that was a threat to safe patient care and my license. She became upset and irate with me. Did I care? No. Patient safety and the safety of my license come first. The fear of harming someone or losing my license was greater than the fear of making her upset by denying her request.
• Know your rights. This is important on any job, but new-grad RNs fail to understand their rights because they’re so consumed with learning the rules and regulations of their employed facilities. During your orientation, take the time to speak to Human Resources about your legal rights. It never hurts to know what legal protections you have at your place of employment.
• Mind your business. When you hear other nurses speak badly of a coworker, don’t join them. Walk away and divert your attention to something else. Entertaining the conversation not only makes you look bad, but is also an easy way for you to get trapped into the role of being negative. Besides, what goes around comes around, and if you start talking negatively about someone, you’re going to be the target eventually as well.
• Always take the time to learn something new. This is a great time to be a human sponge. Doing this makes you look like a team player, and it’s a great way to advance in your career. This also makes you too busy to entertain negative thoughts and/or conversations. Learning isn’t limited to learning nursing skills. You should also take the time to learn about the environment in which you work. Learn what’s acceptable and what’s not acceptable. Also, observe and be mindful of the different personality traits of your coworkers. You may like some and you may not. It’s better to learn in order to be prepared.
• Leave work at work. When you come home, it’s time to relax. Nursing is hard work, and you don’t need to worry and stress about it when you’re at home. Whatever happens at work isn’t to be brought into your personal life. Bringing your work home is a sure way to burn yourself out quicker, and it will make you not want to work at all.
Workplace safety is a topic of major concern and discussion for workers and employers in a variety of occupations and workplace settings. In nursing, patient safety is an essential and vital component of quality nursing care. However, the recent Ebola outbreak and the growing risks of antibiotic-resistant microorganisms have created a heightened awareness around the fact that nursing is still one of the most dangerous occupations in the United States. This raises the following question: Just how safe are nurses in the work setting? In this 21st century, one may easily assume that nurse safety has been addressed. However, the answer is not clear.
Data from the Bureau of Labor Statistics (BLS) show that the health care sector continues to be the most dangerous place to work in America. According to the Occupational Safety and Health Administration (OSHA), health care workers are confronted with the following job hazards: bloodborne pathogens and biological hazards; potential chemical and drug exposures; waste anesthetic gas exposures; respiratory hazards; ergonomic hazards from lifting and repetitive tasks; laser hazards; workplace violence; hazards associated with laboratories; and radioactive material and X-ray hazards. In 2010, there were 653,900 workplace injuries and illnesses in the health care sector, which is more than 152,000 more injuries than the manufacturing sector, according to a 2013 Public Citizen report.
The paradigm for promoting nurse safety is changing, but slowly, and has not kept up with the technology to prevent injury, says Amber Hogan Mitchell, DrPH, MPH, CPH, president and executive director of the International Safety Center. “There have been a lot of advances over the last few decades to significantly improve nurses’ safety, but more can be done to collect and analyze data that would help speed adoption of innovative technology and spur swifter action to revise and implement stronger safety-related best practices and policies.”
The issue of nurse safety is pervasive. Unfortunately, musculoskeletal injuries are common from lifting patients without enough assistance. Nurses lift the equivalent of 1.8 tons every eight hours. Unanticipated exposures to blood and body fluids (BBFs) pose infection and illness risks to nurses on a daily basis. In the process of caregiving, patients or family members occasionally strike out at the nursing staff. Assaults from patients and patient visitors are far from being listed as isolated incidents.
“Health care has reached a critical tipping point,” says Alexandra Robbins, author of the New York Times bestseller The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital. “With looming physician shortages and an increasing demand for services, workplaces will have no choice but to make changes to accommodate nurses, our largest health care provider.”
Clinically Proven Textile Technology
About one in two nurses experience blood exposure, other than from a needle stick, on their skin or in their eyes, nose, or mouth at least once a month, according to a 2012 study by the International Healthcare Worker Safety Center at the University of Virginia. In fact, nurses experience these exposures most often while providing direct care, when they are least expecting it and not wearing protective clothing, according to data from the International Safety Center’s Exposure Prevention Information Network (EPINet).
In order to better protect nurses from unexpected exposures to harmful pathogens, we need to first address the role their daily attire can play in protecting them, says Barbara DeBaun, RN, MSN, CIC, consulting vice president of clinical affairs at Vestagen Technical Textiles, Inc. When exposure is unexpected and nurses are not donning personal protective equipment (PPE), traditional scrubs leave nurses vulnerable to direct contact with harmful contaminants that stay with them all shift long.
“Traditional scrubs allow micro-organisms, blood, and other body fluids to leach through the fabric, resulting in nurses carrying contaminants from patient to patient and home to their families,” DeBaun says. “New ‘active-barrier’ textile technologies, made with fabric such as Vestex, contain fluid-repellent, antimicrobial, and breathability properties.”
Debaun explains that this innovative fabric technology combination is key in helping reduce the acquisition, retention, and transmission of harmful pathogens on health care worker attire. Working together, the fluid-repellent barrier causes harmful contaminants to bead up and roll off the fabric, and the antimicrobial agent limits growth of bacteria on the fabric. Vestex’s active-barrier apparel is currently the only textile technology that has shown clinical effectiveness at reducing MRSA infections by 99.9%, in comparison to traditional attire.
Active-barrier apparel is already available in scrubs and white coats for health care workers and health care facilities to purchase. Hospitals such as Baptist Health in Jacksonville, Florida, have already established a systemwide uniform policy that requires staff to wear active-barrier protective uniforms. The organization made a commitment in 2014 to transition more than 6,000 workers, and all patient attire, to Vestex garments to enhance their culture of safety.
“As more data shows the risk that attire can play in transferring harmful contaminants, we believe that advancements in textile technologies will soon become the new industry standard for nurses in all health care settings,” DeBaun says.
Nursing is the third most dangerous profession in the country because the vast majority of nurses are attacked by the people they are trying to help. According to data from the BLS, U.S. health care workers experience the most nonfatal workplace violence compared to other professions by a wide margin, with attacks on them accounting for almost 70% of all nonfatal workplace assaults and causing days away from work.
In 2014, 68-year-old Charles Emmett Logan, a patient at a Minnesota hospital, attacked a group of nurses with a pipe pulled from his hospital bed. The incident, which was caught on video, showed Logan running through the nurse’s station wielding a metal pole, hoisting it over his head, and hitting nearby nurses who attempted to flee the scene. One nurse suffered a collapsed lung, another fractured her wrist, and others had cuts and bruises. Medical staff told police that Logan, who died in police custody, suffered from paranoia.
“Hospitals do not protect their nurses, and it’s time they do,” says Robbins. “There is so much more that can be done, both tangible changes and major shifts in attitudes.”
Some hospitals believe that posting security personnel near triage looks negative, so they don’t put enough security staff at the entry points to the hospital and near triage. This puts the triage staff at risk when patients who are high, drunk, or psychotic come in the door, explains Robbins.
After the episode in Minnesota, the hospital initiated a training program to teach workers how to recognize and de-escalate potentially violent situations. However, many hospitals lack this basic safety measure — an oversight that leaves caregivers vulnerable.
“Understandably, nurses are focused on providing the highest quality and safest care to their patients, and often at the unintended risk of not protecting themselves,” Mitchell says. “A shift towards promoting a culture of safety that encompasses both patient and worker safety and security can create an overall better, more effective health care environment.”
To help promote a culture of safety, Robbins recommends that hospitals take the following steps:
• Install metal detectors to reduce the chances of patients or visitors injuring nurses and other staff members with weapons.
• Keep a computer database that flags patients known to be belligerent or aggressive.
• Install bulletproof glass and beef up security.
• Practice safe staffing and hire enough nurses so that the nurse–patient ratios are safe.
“The secret to improving American health care is to hire more nurses and insist that workplaces do a better job of protecting our frontline responders,” Robbins adds.
New Policies and Procedures
Exposures to BBFs pose a very large safety risk to nurses. According to data from EPINet, 47.7% of nurses were exposed to BBFs while on the job in 2012. Perhaps even more alarming, from 2003 to 2012, 83.9% had BBFs touch unprotected skin. These rates are high because nurses aren’t protected from unanticipated exposures, and compliance with PPE is surprisingly low. There is mounting evidence as well that nurses’ attire is contaminated with pathogens and can thus become a vector of transmission to other nurses as well as the patients they treat.
Mitchell believes that hospitals need to have programs in place that not only promote the use of PPE, but also measure compliance. This type of surveillance can allow the facility to identify where risks are high and compliance is low, and target programs in those areas, thus reducing exposures and reducing risk.
“EPINet is free to use and is an example of a surveillance system that can help hospitals to reduce risks,” Mitchell says. “The National Institute for Occupational Safety and Health [NIOSH] is launching a national system called the Occupational Health Safety Network [OHSN], and it is compatible with EPINet. Using systems like these allow facilities to compare themselves to others like them and to constantly improve.”
It is important to remember that safety is guided by a hierarchy of controls, which means that it is important first to eliminate hazards and risks to the lowest possible extent. Mitchell says this is done using engineering controls such as safety-engineered devices that eliminate or protect needles (e.g., needleless IV systems, retracting or shielded needles used on syringes, and blunt suture needles). For exposures to BBFs that splash and splatter, engineering controls might include closed systems for suction canisters or spill-resistant specimen containers. It may even include the use of new innovations in textiles, including those that are fluid-repellent and antimicrobial so that BBFs run right off of them, and fluids don’t soak in to the skin.
There will always be more that can be done to address nursing safety risks, Mitchell believes. Organizations like OSHA, NIOSH, and the Association of PeriOperative Registered Nurses, are always open to feedback, and it is only in providing them with your experiences and opinions that they can provide better guidance.
Mitchell adds that addressing nursing safety risks means creating the safest possible working environments and identifying and measuring hazards, so that programs and interventions can be designed to target and prevent them.
“This involves frontline nurses contributing to the review, evaluation, and selection of engineering controls, medical devices, and even textiles used in their hospitals,” Mitchell says. “Finally, it means working together across specialties, across units, across facilities, and across disciplines to share ideas, foster collaboration, and learn from each other.”
Terah Shelton Harris is a freelance writer based in Alabama.
You’re a nurse and love what you do, but you have a nagging feeling it’s time for you to move in a different direction. How do you know for sure it’s time to do so?
Like most nurses you were draw to the profession for a variety of reasons. Maybe it was the schedule, interest in helping others or even the money. You trotted along in your career satisfied by whatever drew you in the first place. But slowly, bit-by-bit, you became disenchanted. You can’t put your finger on it, but deep down you know you most move on.
Some nurses wake up and have a “ah ha” moment that alerts them of the time. For others, it’s more complicated. Typically there are signs you simply can’t ignore when debating when to move on.
- A sense of dread, anxiety, or unease. When thinking about work brings about negative feelings, it may be time to switch jobs. People spend a significant amount of their lives at work and if your job brings you discomfort, why put yourself through it when you can make a change?
- You haven’t received a raise in awhile. Money isn’t everything until you don’t have enough. If you feel like you are not getting a fair wage and haven’t had a bump in pay through additional benefits, bonuses, cost of living raises, etc, after a good amount of time then you may want to consider moving to a different company who values your expertise through compensation.
- You don’t feel like you are growing as a nurse. Personal and professional growth is important to most people. Some positions in nursing don’t lend themselves to growth on behalf of the nurse. If you strive to be the best nurse you can be but your working environment doesn’t encourage it by way of promotion, educational classes or positive constructive criticism, then it may be time to move on.
- You work in a hostile environment. We all know what a hostile work environment is like; constant bullying by co-workers, doctors or sometimes even management. Unsupportive management when issues do come up. Working in a hostile environment can really wear on you and, in the end, it’s not worth your sanity to work in such conditions.
- You want to make a major career change. A major career change could be going back to school for another degree, switching specialties, or even branching out on your own to start your own business! If something major is nagging you to make a move then staying stagnant in the same position is going to cause too much internal turmoil. If you have a goal you want to reach make steps in your life to do so.
In addition to working as a FNP, Nachole Johnson is a freelance copywriter and an author with her first book, You’re a Nurse and Want to Start Your Own Business? The Complete Guide, available on Amazon. Visit her ReNursing blog at www.renursing.com for more ideas on how to reinvent your career.
What’s the culture like at your workplace? Is it generally a harmonious place or does the undercurrent of nurse-to-nurse hostility have you looking for another job?
A hostile environment in a nurse’s workplace is hardly of the raised voice type (although that can certainly happen). “It’s the subtle, nonverbal things,” says Kathleen Bartholomew, RN, MN, author of Ending Nurse-to-Nurse Hostility and other nursing-related books. “It’s your intuition or the conversation that stops when you walk in the room.” We all have a tendency to personalize those incidents and think it’s all about us which has a huge impact on your own morale and how you go about your job.
“Most nurses work in a great environment,” says Bartholomew. To keep that going, communication has to be open and consistent. Nurses, she says, need to be as skilled in communication and creative collaboration as they are in their clinical skills. “But no one seems to teach it,” she says. And often, workplaces don’t encourage feedback unless it’s positive. Often, nurses who are critical are often told they aren’t team players.
What can you do to help reduce and prevent any hostility in the workplace?
“You have to recognize it and be aware of it,” says Bartholomew. “Acknowledge that most behaviors are nonverbal.” Bartholomew says that when verbal and nonverbal cues fail to match up (such as when a colleague rolls her eyes when she sees you coming and then gives you a cheery greeting) most people will react to the nonverbal cues.
Once you recognize it, you have to speak up. It can be something as simple as saying, “I need to talk to you about something in private,” after a colleague is disrespectful or clearly unhappy with her nonverbal actions after getting an assignment.
Sound intimidating? It is, but you can’t let that prevent you from saying something. The business culture, particularly in the United States, isn’t very open to sharing feedback and opinions, says Bartholomew. “It’s in all industries,” she says, “but it’s noticeable in healthcare because the stress is high.”
To keep hostility from brewing in the first place, it’s helpful to ask for feedback and encourage that in your workplace. Bartholomew recommends asking colleges two questions: “What do you like that I do well?” and “What would you like to see me do more?” If you are in a manager position or administrator, recognize that leadership, on all levels, needs to be on board to committing to having a culture that encourages openness. No one will speak up if they feel there will be any kind of retribution.
And if you hear some feedback that’s critical? Try not to have that natural, knee-jerk reaction of getting defensive. To promote openness, you have to take a step back. Start by saying “Thank you for pointing that out,” says Bartholomew. Recognize that we are all human and make mistakes and will not always do the right thing or say the right thing. Be happy that someone is willing to approach you and is taking a step to make a change. Then figure out how to bring that change about.
What ‘s your experience with nurse-to-nurse hostility?
It was an intentionally simple question the clinical nurse in the examining room heard. “Lynn,” I said, “Have you ever been bullied?” There came a pause. Then, she responded with a torrent of emotions reflecting anger and disappointment that took her back to the start of her career 23 years ago. I posed the question as she prepped me for the ECG my doctor ordered.
After completing her nursing degree, Lynn went to work as a registered nurse in the emergency department at a suburban hospital in North Carolina. For the next two years, she was abused, intimidated, openly berated, and humiliated by staff nurses with more seniority and the nurse manager.
“What was that like?”
She said it was just how you were treated. “You were made to feel stupid when you sought clarification of a physician’s charted instructions, for example, or asked for input to correctly respond to a patient’s request. Eventually, I left.”
What happened to Lynn is not a rare occurrence among nurses, unfortunately. On July 9, 2008, The Joint Commission, which provides oversight to over 20,000 hospitals and other care facilities, issued a policy directive to its membership called a Sentinel Event Alert. Its instruction was to have procedures in place to deal with “behaviors that undermine a culture of safety” by January 1, 2009. It described “intimidating and disruptive behaviors” in great detail, which is the most widely accepted definition of bullying. Its rationale was clearly embedded within the body of the policy: “There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care.”
With mounting evidence that bullying was surprisingly prevalent within the health care sector, the intended purpose of the Sentinel Event Alert was to amend its leadership standards. Accredited health care organizations would be required to create codes of conduct that define disruptive and inappropriate workplace behaviors as well as establish and implement procedures for managing such behaviors. Additionally, the institutions The Joint Commission accredits were expected to make their data available for review, according to Gerard M. Castro, PhD, The Joint Commission’s project director for patient safety initiatives.
Nursing’s Dirty Little Secret
“Nurses eat their young,” wrote Theresa Brown, a registered nurse, in an article in The New York Times in February 2010. “The expression is standard lore among nurses, and it means bullying, harassment, whatever you want to call it. It’s that harsh, sometimes abusive treatment of new nurses that is entrenched on some hospital floors and schools of nursing. It’s the dirty little secret of nursing.”
Her story is not exceptional, and it prompted me to contact Gina, a clinical nurse in Worcester, Massachusetts, with a master of science degree in nursing education and 35 years of experience—15 of which were on a nursing school’s faculty.
“There are nurses that I do not assign a new-to-nursing nurse to because of what I know would be their experience,” Gina tells me. Then, she describes her very recent experience where she accepted a per diem assignment in the operating room (OR) of a local hospital with which she is very familiar: “I almost never survived a month because of the bullying that went on. I had never seen anything like it and never experienced anything like it in my years in nursing.”
It seems that there had not been an assignment of someone new to the OR in 10 years, so Gina was treated as an outsider and not part of the clique. So targeted was the hostility that after three months of enduring the treatment, she says, “I began to feel myself spiraling down, losing my self-confidence. I endured badgering criticism; I couldn’t do anything right; there was an absence of kindness.”
Fortunately, there was a change of supervisor who observed the climate in the OR and stepped in to end the intimidation by referring the preceptor for retraining.
An Occupational Hazard
Scenarios similar to the one Gina describes must have been alarmingly common to have prompted The Joint Commission to issue a specific directive regarding workplace bullying, or lateral violence, as it is technically referenced. Diverse studies identify nursing as a risk group for workplace bullying; further, they confirm that the problem of hostility in the workplace is very common in the health care sector.
Indeed, health systems are aware of this hostility and responding to the Commission’s directive. Duke University and the University of North Carolina, for instance, have policies and procedures to deal with workplace behavior. Duke shies away from describing intimidating and disruptive behaviors as bullying per se—and perhaps may have tacitly not reinforced the implications that bullying is specific and disruptive conduct that impacts the delivery of care.
Carole Akerly, BSN, director of accreditation and regulatory affairs at Duke University Hospital, responded to my inquiry. “Duke,” she says, “has identified behaviors that are appropriate and has not specifically described intimidating and disruptive behaviors, and I don’t know whether we have identified it as that close.” But if bullying is as prevalent as the research and reports indicate—and there are many—it is unlikely that Duke and other health care providers have an incident pattern less than the norm.
The University of North Carolina Health Care System, on the other hand, provides a detailed description of intimidating and disruptive behavior and a very specific description of what constitutes appropriate behavior, so the employee has no room to allege ambiguity. The rationale for its disruptive and inappropriate behavior policy admits that disruptive behavior “intimidates others and affects morale or staff turnover [and] can be harmful to patient care and satisfaction as well as employee satisfaction and safety.” Further, the policy acknowledges the possible presence of such behavior: “While this kind of conduct is not pervasive in our facilities, no hospital or clinic is immune.”
Carol F. Rocker, PhD, RN, the lead investigator of a study of nurse-to-nurse bullying and its impact on retention in Canada, reported in OJIN: The Online Journal of Issues in Nursing in September 2008 that Canadian nurses are not alone when it comes to workplace bullying and emphasized that workplace bullying among nurses is now recognized as a major occupational health problem in the United Kingdom, Europe, and Australia. Why did The Joint Commission go to the trouble of defining bullying if it was not to delineate behaviors that threatened patient safety and care quality? The answer is embedded in what led the Commission to do this in the first place. It’s found in the promulgation of the Universal Protocol (UP).
In addressing the need to create a climate of safety related to wrong site, wrong patient, and wrong procedure within a health care facility, the Commission became aware that one of the contributing factors was the failure to speak up. What stops a clinician from speaking up? Oftentimes, it’s the deference to the physician and other clinicians.
“We have heard of abusive behavior by physicians when clinicians in the operating room, for example, have corrected the physician. Not speaking up is the result of deference to the physician,” says Castro. The UP team became aware at that time that this harmful behavior within care facilities was a safety issue.
A 2003 survey on workplace intimidation conducted by the Institute for Safe Medication Practices found that 40% of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator. Elaborating on this issue, the Commission’s Sentinel Event Alert cites several reasons why disruptive behaviors go unreported, such as fear of retaliation, the stigma associated with “blowing the whistle” on a colleague, and leniency towards physicians who generate high amounts of revenue.
But, so serious is the epidemic of workplace bullying—with particular emphasis on the nursing sector—that 26 state legislatures have proposed legislation to address this concern, beginning with California in 2003. The model, the Healthy Workplace Bill, provides very specific employee and employer remedies, protections, and sanctions. There is clearly a movement to expand safety in the workplace from the purely physical aspect to the equally important emotional and psychological aspects.
When Nurses Hurt Nurses
Kathleen Bartholomew, RN, MN, renowned for nursing consulting and training, cites episodes of nurse bullying that astonishes: a nurse hides a surgeon’s favorite instrument when a substitute fills in as the scrub; a circulator, a nurse who makes preparations for an operation and continually monitors the patient and staff during the surgery, doesn’t tell a new nurse who is scrubbed that she knows the shunt the surgeon selected has fallen on the floor; a newly hired RN who was previously a scrub technician is shunned by both camps. These episodes, Bartholomew says, pose the question whether this is what life is like in the OR.
When the administration at Indiana University Ball Memorial Hospital studied the issue of bullying, it was clear that the problem existed beyond nursing units. “It starts with physician to physician and then trickles down the chain of command,” says Renee Twibell, PhD, the lead investigator and an associate professor of nursing at Ball State University. “If the doctor kicks the nurse, that nurse turns around and kicks the new nurse or the CNA.”
The consequences of adult bullying have led investigators to name it as a significant occupational stressor in the workplace. Moreover, the Center for American Nurses labels workplace bullying a serious issue affecting the nursing profession in particular, and defines it as any type of repetitive abuse in which the victim suffers verbal abuse, threats, humiliating or intimidating behaviors, or behaviors that interfere with the victim’s job performance and are meant to place the health and safety of the victim at risk.
Are all nursing sectors equally at risk? Specifically, I was curious to know whether military nurses have a similar experience. Having spoken with Lieutenant Colonel Angelo D. Moore, PhD, the deputy chief for the Center for Nursing Science and Clinical Inquiry at Fort Bragg Womack Army Medical Center for a previous story, I remembered what he had said. Moore turned my inquiry around and wondered whether gender issues might be at work in some bullying episodes. The ratio of male to female nurses in the military is thrice that of the nonmilitary nursing sector and, according to Moore, the combination of having been to war and the culture of the military contributes to very few incidents where bullying was alleged.
Still, bullying is a complex phenomenon. Although bullies are responsible for their behaviors, investigators have analyzed several potential factors that prime the workplace for bully behaviors, which include organizational leadership and culture, the social system, character traits of the victim, and character traits of the bully. Bullying clearly qualifies as hostile workplace behavior, and if the target can claim protected class status, it becomes a major legal issue for hospitals and care centers. A 2011 study of student nurses by the American Nursing Association reported that 53% of study participants had been “put down” by a staff nurse, and 52% had been threatened or experienced verbal violence at work.
Cheryl Dellasega, PhD, faculty member at the Penn State University College of Medicine and author of When Nurses Hurt Nurses: Recognizing and Overcoming the Cycle of Bullying, provides significant research that led her to state that there are cases where the nurse manager or charge nurse—often a highly competent, valuable nurse that the administration does not want to lose—may act as a bully, playing favorites when it comes to assignments or time off. “If they are role modeling this stuff, it will be worse among the staff,” Dellasega told NurseZone.com. “If they get the message that it’s OK to treat people like this, everybody will.”
So, what’s the remedy? Bullying in the workplace is both an awareness and a leadership issue. Moreover, as is so often the case in workplace practices, the leadership should be careful not to be caught being party to making case law by a complainant seeking to link hostile workplace to bullying as a protected class member. Hospital management might address the presence or prevalence of bullying behavior by examining how it is factored into their training in root-cause analysis, as well as what their whistleblowing protection policy provides.
Nurse leaders must establish clear guidelines about what behaviors will not be tolerated and what is unacceptable, Dellasega believes. She also recommends creating a suggestion system so nurses can anonymously report things that happen on the unit, and asking for feedback about what would make the work environment better.
Gabriela Cora, MD, takes a harder stand, saying hospital administrators should have zero tolerance for bullying behavior. “Lay a plan for improvement,” Cora adds. “Reward them when they improve their behavior and be ready to fire them if they continue the bullying behavior. Second, avoid praising or rewarding nurses for their work performance if they are bullies. Instead, respectful treatment of patients and positive interactions with colleagues should be rewarded.”
Ultimately, it’s all about modeling positive behaviors and holding employees accountable. If the policy is zero tolerance for bullying, it should mean just that—zero tolerance.