Spotlight: Nursing & Bullying

photo credit: istockphoto.com

We’ve had several requests to write a story on bullying in nursing. It’s a hot topic these days – workplace bullying, in general, seems to be escalating. Partly, our awareness has increased, so we’re more aware of bullying behaviors that may previously have been accepted, if not acceptable. As our awareness has increased, so has our knowledge of the complexity and subtlety of the many ways that bullying manifests. And, with the rapid evolution of technology, if you don’t know how to control your bullying instincts face-to-face, well, let’s just say, “there’s an app for that.”

What is workplace bullying? The Workplace Bullying Institute uses the following description:

Workplace bullying is the repeated, health-harming mistreatment of one or more persons (targets) by one or more perpetrators. It is abusive conduct that is:

• Threatening, humiliating, or intimidating, or
• Work interference — sabotage — which prevents work from getting done, or
• Verbal abuse

Nursing is a female-dominated profession, and, for better or worse, bullying in nursing is predominantly through typical female patterns of aggression – verbal and relationship bullying, rather than physical bullying. Don’t think male nurses are exempt, however. A Norwegian study from 1999 found male nurses were more likely to be bullied than females (perhaps being the minority in that profession puts them at higher risk)

Here are some examples of what bullying in nursing looks like in action:

• Yelling
• Condescending language or tone; Bossy, arrogant
• Negative body language – eye-rolling, etc
• Impatient with questions
• Ignoring questions or request for help; The silent treatment
• Public belittling and embarrassment (about quality of work or other professional or personal items)
• Gossip, rumors
• Work-related interference: removing responsibilities, assigning too-heavy workloads, assigning low-skilled work; withholding information needed for successful completion of job; blocking promotion paths
• Taking credit for another’s work
• Exclusion from social events, in and out of work

Bullying can come from all directions – from someone at (approximately) the same level or perceived power, from above, or from below. It’s often called horizontal or vertical bullying (although that over-simplifies a bit). In nursing, horizontal and vertical bullying can take the form of:

• Nurses of the same level bullying one another
• More senior nurses bullying nursing students or newly assigned nurses
• Nurses bullied by physicians
• Nurses bullied by nursing or administrative supervisors
• Nurses bully patients or their families
• Nurses are bullied by patients or patients’ families

Sounds pretty bleak? It’s not all bad, and many of the nurses we know have had wonderful, supportive experiences in nursing school and in their various placements. However, nursing has a bad reputation for bullying, especially nurse-to-nurse.

We know that being a bullied target in a nurse’s uniform has all the same problems as anyone experiencing workplace bullying (or school bullying, for that matter).

• Health Problems. Depression, anxiety, anger, PTSD, decreased energy, sleep disturbances, appetite changes, to name a few. Family relationships suffer.
• Work Performance Problems. Lack of initiative, lowered creativity, increased absenteeism, lack of energy, “infectious” bad morale, heavy use of Employee Assistance Programs.
• Serious Problems Ahead. Bullying, or any type of prolonged excess stress, can also result in very bad “self-calming” behaviors – excess drinking and drug use, for example. These behaviors are bad in anyone, but especially risky in health care professionals.
• Employers Lose Too. It’s expensive and dangerous for employers (hospitals and other health care organizations) to be routinely short-staffed and constantly needing to scout, hire, and train the revolving door of employees who leave when bullying becomes too bad. The everyday loss to productivity for those dispirited employees remaining on the job, has been estimated as high as 40%. It’s well-known that the brains of employees (or students) in bullying environments are diverted from full attention to their work (or school work). A significant background portion of your brain remains on alert in these unpredictable environments, protecting you, always ready for fight or flight.

Bullying can compromise on-the-job performance in life-threatening ways. Here’s a worrisome finding. A 2004 survey by the Institute for Safe Medication Practices found that workplace bullying in health care posed a critical problem for patient safety: Rather than bring their questions about medications orders to a difficult doctor, almost half of the health care personnel surveyed said they would rather keep silent. Equally concerning, 7 % of the respondents said they had been involved in a medication error in the past year in which intimidation was at least partly responsible. It’s hard enough to be a patient without having to worry that some of the safety mechanisms around you may be disabled.

Nursing – and health care, in general – is a stressful occupation. Literal life-and-death decisions are routinely made. Health care providers, especially those who work in hospitals, including the subset of surgeons, surgical nurses and technicians, ER personnel, ICU, CC, NICU, and first responders, etc, have above average stress coping skills and the ability to function well in a routinely high-pressure, high speed environment. Clearly, they don’t faint the sight of blood, but there is a limit for even the most stress-hardy individuals.

Do we really want people who make key, life-influencing decisions to be (1) extra stressed from working in bully-filled environments or (2) afraid to speak up, ask questions or clarify, even when they know the need to be clear and select the right treatment is important, perhaps crucial, to a patient’s well-being?

Sleepless nights, rotating shift work, long shifts, filling in during times of short-staffing, etc all add structural stress to the content stress of the job. Employers need to be aware of the additional stress they may be contributing, either by ratcheting up the stress of the work schedule or by allowing bullying to continue once management becomes aware there’s a bullying issue brewing.

Stress fuels bullying. In everyone’s life, stress undermines performance AND it makes you more likely to become a bully. When you‘re at the edge of your ability to handle your own stress, it’s very easy to slip across the line into being a bully yourself, without intending to or recognizing it. Stress handling is a key skill, for bully and target, especially in environments where high stress comes with the job. Meditation, exercise, healthy eating, and laughter do a lot to help improve the brain’s ability to handle stress.

Temporary Coping Strategies. While we’re trying to shift the culture, we need to have some protective policies in place. For example, some hospitals have a “code pink” for nurses in trouble or being bullied. That’s a coping strategy. The best strategy, however, is heading it off much earlier, before the problem needs a full-scale intervention.

Let’s continue the conversation. This article has focused on understanding the nature and cause of bullying in nursing. Next Step: What’s the cure?

For those of you who are (or have been) nurses or other health care providers, or those of you who have worked with nurses, here are some of the questions we want to hear about from you:

• What type of bullying do you see most in nursing? Is it vertical (nurses to physicians or supervisors) or horizontal (nurses to other nurses)? Where does nurse-patient (or patient’s family) bullying fit in?

Note: It’s never exactly vertical or horizontal, but what’s key is the real or perceived power differentials. Use your own experience to describe the key issues and symptoms

• What do you think is causing bullying in nursing?
• Can you make a few suggestions for how to prevent it?
• Make some suggestions for how to manage the problem while we’re trying to shift the culture? For example, “code pink,” mentioned earlier, is a coping strategy.

Send us your thoughts and watch for our next article on bullying in nursing, which will focus on prevention and repair strategies.

Learn More:

L Blumen, Bullying Epidemic: Not Just Child’s Play, Camberley Press, 2011

Cheryl Dellasega, Bullying Among Nurses, American J Nursing, Vol 109, No 1, p 52-58, Jan 2009

Institute for Safe Medication Practices, Survey Shows Workplace Intimidation Adversely Affects Patient Safety, Mar 31, 2004

Workplace Bullying Institute