Bullying in a Least Expected Place

Bullying in a Least Expected Place

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.”

Moving Forward                                                    

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.


5 Workplace Violence Prevention Tips

5 Workplace Violence Prevention Tips

With today’s news about a hospital shooting in Boston, workplace safety for nurses is again foremost in many nurses’ minds.

And while nurses often run the risk of workplace injuries like muscle pulls from moving patients to something as serious as a needle stick, the idea of a hospital shooting is almost unthinkable. As today’s news shows, it happens.

How can nurses remain protected from workplace violence?

Be Aware

It goes without saying that being aware of your surroundings and what is happening in your environment is standard safety protocol. Nurses know that things happen fast in a hospital and that seconds matter. Practice being aware of your surroundings in all kinds of scenarios. For a challenge, note the descriptions of people around you, of family members accompanying patients, of clusters of people, or even of out-of-place bags or objects. Make a habit of it and soon it will become second nature. Awareness is critical to your safety.

Trust Your Instincts

Do you ever get a funny feeling when something doesn’t feel quite right to you? That’s your instinct telling you to pay attention – trust it. If a situation feels like it is getting out of control, call in help and notify your colleagues. It’s better to call attention to something harmless than not mention something or someone that is potentially threatening.

Know Your Workplace Security Procedure

Do you have security on staff or do you rely on local police for problems? Review the procedure for different scenarios with your staff or request it from your supervisors. You should know what to do in all kinds of situations – an agitated patient, an armed family member, unrest outside that overflows into your workplace, a fight. All those situations have the potential to turn violent in an instant. Your protection comes from knowing what to do.

Speak Up

If your workplace is lacking in basic workplace violence prevention measures, demand change. Find out what will help protect you and your colleagues and bring your ideas to the attention of your supervisor and administration. Ask your legislators to support workplace violence prevention laws and programs. And always report any incidents of violence in your workplace.

Learn More

Workplace violence is such a hot topic that the Centers for Disease Control even has a course for nurses. The Workplace Violence Prevention for Nurses addresses the unique nature of violence in a health care setting. Work with local nursing organizations and local and national government officials to make workplace safety in a health care setting a priority. Consider taking a personal safety course so you know how to protect yourself if needed.

Workplace violence can happen anywhere, but nurses know the unique atmosphere of a health care setting can change rapidly and without notice. Keeping yourself safe is the best way you can help yourself and your patients.

“Nerdy Nurse” Offers Lateral Violence Resources

“Nerdy Nurse” Offers Lateral Violence Resources

Ever heard the expression “Nurses Eat Their Young”? Somehow it’s meant to be humorous, though those who’ve experienced that abuse know it’s anything but.

Perhaps you, right now, are a victim of a of bullying from other health care “professionals.” Where can you turn? First, take a look at what Brittney Wilson, RN, BSN, the blogger behind thenerdynurse.com, has compiled on the topic.

She has been researching and sharing her findings about the topic ever since experienced nurse-on-nurse bullying during her three years as a floor nurse, many years ago. Now it is one of her areas of expertise.

It’s important to start in the right place on the Nerdy Nurse’s comprehensive site, so you don’t get lost.  (It also covers technology topics – thus the name – as well as items of interest in the day-to-day life of nurses, such as the most comfortable shoes for men and women).

My pick for where to begin your research is this post, called “Nurses Eat Their Young: Resources for Lateral Violence” because in it Brittney curates from all over the web and beyond. These are resources that she herself found or that readers submitted to her – all are useful.

You can go to the type of resource that appeals to you: books, scholarly articles, posts from around the blogosphere, discussion forums, and CE credit offerings from professional organizations. And the list of options under each category is not skimpy – I counted 12 articles.

For a detailed resource on lateral violence and nurses, you may want to choose from these three books that Brittney recommends:

  • Confident Voices: The Nurses’ Guide to Improving Communication & Creating Positive Workplaces – By Beth Boynton RN MS
  • Ending nurse-to-nurse hostility: why nurses eat their young and each other- By Kathleen Bartholomew
  • From Silence to Voice: What Nurses Know and Must Communicate to the Public – Suzanne Gordon & Bernice Buresh

For my money, the personal experience posts on The Nerdy Nurse site itself are the most instructive (she also lists them under their own category). You get a blow-by-blow (excuse the term) account of a young nurse’s life was made a living hell by a group of hostile co-workers, and how she overcame the abuse.

In one blog post (titled “Respect and Dignity”) Brittney gives this overview of her situation – it’s gripping:

“I was being called a liar, incompetent, and made to look a fool. At the most difficult point in my young life, pregnant, postpartum, the death of my mother, and as a new grad nurse, I had this lovely stressful nugget to add to my plate. Everyday I had to make the best of the situation where the other nurses refused to help my patients and I suffered. Unlike many, I did speak up, and often. Yet for fear for the loss of my job, and the livelihood of my family, I kept continuing to go to an unsafe work environment in the hopes that eventually, somehow, it would stop.”

You’ll find a lot of value in reading Brittney’s other posts about how her story twists and turns, first to another shift (away from her tormentors), and then into a new direction — clinical informatics.

How about you – do you have a favorite resource that helps you deal with a hostile work environment? If so, we’d love to hear about it.

Jebra Turner is a health writer in Portland, Oregon. Visit her online at www.jebra.com.

Nurse: Are *You* The Bully?

Nurse: Are *You* The Bully?

Many nurses are sensitive to bullying behavior from others in the workplace – fellow nurses, doctors, administrators, and even patients – but not to that of their own. Bully or bullied, it’s no fun to experience a hostile healthcare workplace.

For example, though it’s often said that “nurses eat their young.” Those same recent grads may find themselves more competent in some areas than older nurses, such as being tech-savvy.

They then don’t hesitate to give their elders abuse about discomfort using new technology, say. They may use the impatient, hostile voice, or rude body language (eye rolls?) that they may suffer in their first years on the floor.

Sometimes a nurse can be both a victim and a perpetrator at the same time. Or in different situations. Or with different co-workers. Or on a different shift. Or with a different nurse manager. Or when especially stressed.

It pays to look honestly at how you relate to others in your workplace so that you can stamp out your own bullying behaviors.

Laura A. Stokowski, RN, MS, provides a detailed list of bullying behaviors that many experts have identified in A Matter of Respect and Dignity: Bullying in the Nursing Profession on Medscape Nurses, Here’s a short excerpt from that piece:

  • Refusing to speak to a colleague, being curt, giving the “silent treatment,” or withholding information (setting someone up to fail);
  • Unwarranted or invalid criticism, excessively monitoring another’s work;
  • Physical or verbal innuendo or abuse, foul language/swearing;
  • Raising one’s voice, shouting at or humiliating someone;
  • Treating someone differently from the rest of the group, social isolation;
  • Asking inappropriate and/or excessive questions about personal matters or teasing about personal issues;
  • Gossiping, spreading rumors, assigning denigrating nicknames.”

If any of these behaviors seem familiar because you yourself tend to resort to them, that’s probably an uncomfortable realization. Give yourself credit, though, for admitting to the truth. Now you can go about fixing the problem, because in the final analysis — even bullies don’t like bullies.

Jebra Turner is a health writer in Portland, Oregon. You can visit her at www.jebra.com.

“The Nerdy Nurse” Blogs on Bullying

“The Nerdy Nurse” Blogs on Bullying

Brittney Wilson, RN, BSN, also known as “The Nerdy Nurse,blogs at thenerdynurse.com and authored The Nerdy Nurse‘s Guide to Technology. But a love of technology wasn’t the genesis of her blogging journey.

“What led me to starting my blog was a negative experience as a floor nurse. I was bullied by most everyone in the department. I complained to everybody I could, but nothing happened,” she remembers. “Then I went online to see if anyone had experienced some of the same things and could maybe help me. I started compiling information on lateral violence in nursing, and sharing it on my blog.”

Wilson worked on that floor for three years, and finally did see improvement in the bullying situation. But it came after she’d decided to train in clinical informatics as a way of combining her interest in both nursing and technology.

What turned things around? Plenty of difficult conversations with her manager and HR. “My boss got disgruntled with me when I brought up the term harassment. But then she backed off. Basically, when I let her know that I felt she was allowing the situation to occur, and that legally it was an issue, then her tune changed,” she explains.

“Also, I was ultimately moved to night shift. Getting away from the toxic nurses really made a big improvement, and I think being on night shift and being ‘out of sight/out of mind’ of the manager made things much easier for me.”

Wilson encourages nurses who are being bullied to speak up. Ask co-workers and even patients who witnessed the harassment to speak to management, but don’t count on it. Ask your manager to conduct an investigation into your claims by interviewing other staff members.

What if that doesn’t improve the situation? Wilson suggests 
a bullied nurse first start with “their manager, then director, then DON, and possible even the CEO. A nurse must make sure he/she has attempted to follow the chain of command before involving someone from outside the organization.” 

After that, consider then involving your nursing organization (if a member), state board of nursing, accrediting agencies, and news organizations.

Wilson believes that blogging about her personal experience of being bullied helped make her stronger as a person and as a nurse. (Sometimes growth is painful.)

Though the treatment she experienced from the bullies on her floor could never be excused, it ultimately led to her new career in informatics and a blog that’s helped other tormented nurses to survive and thrive.

Jebra Turner is a health writer in Portland, Oregon. You can visit her online at www.jebra.com.

What to Say When You’re Being Bullied

What to Say When You’re Being Bullied

Nurse-on-nurse bullying. Lateral violence. Hostile work environment. These are common terms for what’s sadly a common situation in many health care environments.

If you’re being bullied, it can help to have a “script” that helps you face your harrasser. Peggy Klaus, a Berkeley, California, a leadership and communication coach, has taught courses on difficult conversations for nurses, physicians, and medical students.

Here she offers some recommendations but doesn’t propose a one-size-fits-all solution. “We each have our own level of tolerance,” explains Klaus, “You have to be vigilant and see how it’s affecting you, and how it may be impeding your effectiveness. That’s especially important when you’re working in the crucial role of a nurse.”

1. Talk to your supervisor.  Assume that nursing leadership is going to want to be helpful. (Many hospitals are anxious to put a stop to employee-to-employee harassment, if only because it places them at risk for lawsuits, for allowing a hostile workplace or retaliation if they a nurse who has made a formal complaint.)

One possible script from Klaus…

“Have you ever been bullied? What did you do to solve the problem?”(Makes the conversation more personal, and you’ll be more likely to elicit empathy from your supervisor.)

“I’m concerned because If nurses aren’t being collegial, it greatly affects the hospital.” (Don’t emphasize your own distress as much as downsides your supervisor can relate to.)

“Patients don’t get the kind of care they need, our evaluations as individuals and as a group will suffer. I’ve been thinking a lot about this problem. I would be doing my group a disservice if I didn’t bring this up.”

2. Ignore the bullying. If that’s a possibility for you, you can decide to play along, be civil and respectful, and just go about your business.

“Don’t play low status, though,” says Klaus, “which comes out in verbal and nonverbal behaviors such as having slumped shoulders or ending sentences with an upward inflection as if asking a question or seeking approval.”

3. Confront the bully. Be direct, assertive, and respectful and talk alone in a private, confined space, such as a conference room. Group confrontation doesn’t work, so talk first with the lead bully, and if necessary, repeat with the others.

One possible script from Klaus:

“I’ve recently noticed behavior or signs that you’re trying to bully me and I want it to stop.” (Give a couple of examples and say how it affects you.)

“I really want to work this out between us and not involve higher ups or human resources.”

Ask for the bully’s input and end on a positive, affirming note: “I look forward to working well with you.”

If the behavior changes, but then the bully slips and starts up again, go back and have the conversation again.

“You know, things had gotten better but I noticed that this is increasing and it’s got to stop.”

4. If the bullying doesn’t stop, go higher up the chain of command until you get relief.

Jebra Turner is a health writer in Portland, Oregon. You can visit her online at www.jebra.com.