Nursing is a profession of service to others. Daily, nurses meet the physiological, psychosocial, and spiritual needs of the patients and patients’ significant others to whom health care is provided. The provision of quality, safe, evidenced-based practice nursing care is delivered by nurses in both inpatient and outpatient health care settings. However, the provision of nursing care can be significantly impacted when nurses are not provided safe environments to work within.
In 2018, I had the opportunity to work with my fellow nursing colleagues on the American Nurses Association (ANA) Professional Issues Panel #endnurseabuse. The panel was an advisory committee consisting of nurses throughout the United States. Our mandate, to critically and honestly discuss workplace violence perpetrated against nurses. I commend the ANA on their stance on violence against nurses in the workplace perpetrated by such entities as visitors, patients, intimate partners, nurses-to-nurses, and others, as well as their 2015 position statement on bullying, incivility and violence within the workplace. In 2019, Ambrose H. Wong, M.D., MSEd, Jessica M. Ray, PhD, and Joanne D. Iennaco, PhD, PMHNP-BC, APRN, noted in an article written within The Joint Commission Journal on Quality and Patient Safety, that “Health care workplace violence is a growing, pervasive, and underreported problem.” Of concern is that despite the identification of the problem of workplace bullying and violence, it remains an ongoing issue.
Enough is Enough
Workplace violence can consist of both physical and psychological threats against others. While bullying can become physical, perpetrators tend to use negative words (i.e., humiliation, backstabbing, verbal abuse) to gain psychological intimidation over their victims. In February 2019, as I sat within a Sigma Theta Tau International conference on healthy workplaces breakout session, a normally quiet person, I found myself verbalizing the words, “Enough is Enough,” as stories were shared of working with disrespectful nurse colleagues in clinical and academic settings. I have been a nurse for over 29 years and became a nurse to administer care to the physically and mentally ill. It is a privilege to help in the healing process of others. If I would have known that violence and bullying was tolerated within the nursing profession as a normal ritualistic patterned behavior, I may have rethought my entry into health care.
Alas, I am a nurse for life. And although I have contemplated leaving the profession I never will. The truth is, I love being a nurse and I love caring for patients. And, I enjoy the collaboration that occurs with my colleagues that leads to positive health outcomes with patients we jointly care for in clinical settings.
And so, I am challenging my nursing colleagues in clinical and academic settings, nursing leadership, and nursing health care organizations, to take back our profession by deeming violence and bullying in nursing as not being acceptable. By ignoring violence and bullying in the workplace, nurses perpetuate the cycle of anger and violence. The co-existence of anger and violence in health care environments will continue if nurses do not deem these behaviors as harmful to our profession. As a profession of caritas that places the safety and health of others as a priority, we must take this professional ideal and transfer it not only to the care of our patients, but our care for one another.
Ways Nurses Can End Violence and Bullying
Nurses are wonderful advocates for patients. Let’s become advocates for one another. If you observe bullying or violence within the health care environment, report it (i.e., notify your immediate supervisor, nursing leadership, and human resources). Calmly acknowledge that you have observed the behavior of the perpetrator and affected nurse and ask, “Can I assist the two of you in anyway? There appears to be a disagreement of some kind.” This places the bully or potentially violent person on notice that others have witnessed their behavior.
Nurses can educate themselves on how bullying and violence presents itself in the workplace by becoming familiar with the ANA Code of Ethics with Interpretative Statements, the United States Department of Labor Occupational Safety and Health Administration (OSHA) workplace guidelines, and The Joint Commission’s stance on workplace bullying and violence. Additionally, there are now several nursing articles that can provide further insight on behaviors that can negatively impact health care environments, health care workers, and patients. A list of current websites is provided in the sidebar for your reference and support.
Together, nurses united can create healthy and supportive workplace environments for all!
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.
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