THE NURSING PROFESSION is based on caring, compassion, education, and healing. Despite an emphasis on these components, however, nurses have a reputation for eating their young. This incivility continues in today's healthcare environment, and many nurses are leaving healthcare organizations or abandoning the profession entirely as a result.1 Nurses departing hostile work environments place additional strain on the profession and further perpetuate academic and bedside nursing shortages, yet workplace bullying continues.
Using education, evidence-based strategies, and professional behaviors, nurses can eliminate incivility and bullying. This article defines the terms associated with bullying, identifies two types of bullying behaviors, and discusses anti-bullying strategies.
In this article, perpetrators is the term used for those who carry out acts of bullying, targets are the intended victims, and witnesses observe the abuse.2-4 (See Coming to terms with bullying.)
Bullying fosters errors
With high patient loads, stress, and chaos in the workplace, the complexities of nursing and patient care create an environment conducive to bullying.1,5,6 Working in such an environment can erode the confidence, ability, and teamwork of the entire staff. Patient care is crisis-focused,6 and nurses are further challenged to focus and complete tasks when bullying adds to their workload.
In 2015, Rainford and colleagues published “The Disruptive Force of Lateral Violence in the Health Care Setting,” which reported that approximately 97% of nurses have either witnessed or been targets of workplace bullying.6 Typically, a perpetrator targets a coworker who is passive and easy to challenge, sway, or lead. As a result, the target's attention is shifted from the patient's needs to the perpetrator's behaviors, adding stress, impairing concentration, and potentially leading to medical or patient-care errors.7
Both The Joint Commission and the American Nurses Association (ANA) support safe workplace practices in healthcare organizations.8 In 2009, The Joint Commission put a code of conduct into place that required all accredited organizations to address disruptive and inappropriate behaviors.9 It also recommended that organizations offer staff education, develop processes for surveillance and intervention, and enforce the code of conduct to hold individuals accountable for their behavior. Bullying prevents communication and teamwork, each of which is necessary for safe patient care. In 2016, The Joint Commission reported that bullying increases medical errors, decreases patient satisfaction, and contributes to adverse patient outcomes.10
In 2015, the ANA released a position statement announcing that “the nursing profession will no longer tolerate violence” or bullying in the workplace, which provided a clear vision for ensuring the safety of patients and staff.11 Nurses were encouraged to participate in educational programs and prevention strategies, understand their organizational policies, and implement strategies for conflict resolution with respectful communication. The statement established that both staff and employers are responsible for creating and sustaining a safe and trustworthy work environment.
Bullying behaviors and circumstances
Workplace bullying is the exercise of control, manipulation, or power using specific behaviors. Covert behaviors such as withholding information or excessive supervision can be subtle and difficult to acknowledge or prove. Overt behaviors are openly hostile and easily identifiable. 5,6,8,12,13 (For examples, see Bullying behaviors in the workplace.)
Bullying can happen to staff at all levels, regardless of title, seniority, or ability. Each of the following situations presents a variation of bullying that will erode communication, trust, and teamwork in healthcare settings:
- A group of nurses talk softly and abruptly stop when another approaches.
- A new graduate nurse asks her preceptor about the organization's morning assessment expectations; the preceptor responds, “You went to which nursing school?” or “Didn't they teach you how to do an assessment in nursing school?”
- A nurse is asking questions about a new patient during a shift change. The outgoing nurse ignores the nurse and walks away without answering, withholding key patient information.
- A nurse manager confronts a nurse publicly at the nurse's station about a patient situation or medication error.
The high cost of bullying
Incivility is detrimental to patient care, as victims of workplace bullying may find themselves struggling with critical thinking, focus, and timely patient care. Additionally, patients and families may be keenly aware of bullying within a unit, which can negatively impact patient satisfaction scores.
Targeted staff members can experience physical, physiological, and mental stress when subjected to workplace bullying. Physical and physiological signs and symptoms of bullying include fatigue, insomnia, gastrointestinal disorders, eating disorders, headaches, and hypertension.5,6,8,12,13 Mental and emotional signs and symptoms include anxiety, depression, fear, poor concentration, feelings of powerlessness, panic attacks, ineffective coping strategies, poor self- and work-image, posttraumatic stress disorder, and, in some cases, suicide.5,6,8,12,13 Targeted staff members are focused on self-preservation and avoiding the perpetrators, relegating patient care to a lower priority.
Workplace bullying infiltrates the home and personal environments, and the negative effects can disrupt work-life balance along with self-esteem, self-worth, and a nurse's career path. It also inhibits learning, which could prevent nurses from reaching their full potential.1 This behavior directly impacts the unit with an overall negative culture, low morale and productivity, poor teamwork, and increased staff absenteeism and burnout.
In dealing with high staff turnover, employers face costly hiring challenges and must allocate funds to advertise, recruit, and hire new staff. Accounting for the costs of the orientation process, the new nurse's salary, the required educational courses, and additional training and mentorship, the financial loss of losing and replacing a nurse can be up to $100,000 depending on his or her orientation length and skill level.14
Nurses who are targets or witnesses to bullying behavior must remember that perpetrators are seeking to exert control over another person. Bullying is about establishing dominance over the target, but it is not about the target's performance.14 The following strategies help address and combat workplace bullying.
Calling out the behavior. This is the act of verbally addressing the perpetrator. To witness bullying behaviors in silence is to accept them. When staff members intervene, it creates group resistance rather than silent support and decreases the perpetrator's power.12
Scripting and phrases. Creating a message and practicing a dialogue before the confrontation helps nurses feel more confident when approaching a bully. Several examples of phrases or scripts include the following:5
- “I don't think your tone is appropriate.”
- “I'm not sure you're aware that your tone comes across as sarcastic...”
- “Your tone is accusatory.”
- “When you [state behavior(s)], I feel [state feeling(s)] ...”
If the situation escalates, the staff member should walk away from the hostile situation.
Bullying events need to be addressed immediately by utilizing any of the phrases or scripts. Address the perpetrator in a calm and professional manner, and remember to keep it simple.15 When perpetrators are addressed consistently, bullying behavior will be reduced as a no-tolerance policy is established.9
Documentation and record keeping. An important strategy is to document each incident. Managers and organizational leaders need this documentation to substantiate patterns of abuse and intervene. Keep a journal of all occurrences of workplace bullying. Include information on the times, dates, facts about the incident, and any witnesses. Keep to the facts of what was said and stay away from subjective information or editorializing. Keep all documentation and provide copies to managers and leadership. This information will be used during any formal complaint meetings.
Follow the chain of command
Addressing a perpetrator is not easy, but the early involvement of management or a supervisor can provide aid, leverage, and authority. Vertical bullying, which creates a difficult work relationship and requires the victim to contact the next-in-line manager or supervisor, creates additional challenges. Nurses need to understand their organization's policies and procedures relating to codes of conduct, safe work environments, and zero-tolerance policies and refer to them when documenting workplace incidents. They must also review their employer's chain of command policy, which offers direction for employees looking to report a problem.
If a target finds the perpetrator's behaviors persist despite incorporating the strategies described above, the next step is to schedule an appointment with a leader, such as the nurse manager or a clinical instructor, according to the chain of command. It may be best to schedule a meeting outside of your usual shift to communicate importance. Bring any documentation.
If the situation continues despite the meeting, it may be time to pursue continued options such as going further up the chain of command or contacting Human Resources (HR). If a supervisor or manager is the perpetrator, speaking to his or her supervisor or manager is appropriate. Similarly, managers should also utilize the chain of command, involving HR early to promote administrative awareness or obtain additional support.
HR personnel are highly trained professionals educated and skilled in dealing with workplace bullying. They understand the detrimental impact of workplace bullying on the staff, unit, and organization. They are also aware of potential lawsuits. The documentation of incidents, description of behaviors, impact on patient care, potential resolution attempts, and any formal meetings with a leader will assist HR in stopping these behaviors.
What if bullying continues or escalates?
In a perfect world, that would be the end of it. In reality, however, the bullying behaviors may not stop—they may even escalate. In these scenarios, many nurses opt to leave the unit or even to resign from the organization, and this can be an acceptable option to protect the nurse and his or her license.
Whenever possible, nurses should request an exit interview to provide insight and reasoning as to why staff members are leaving particular units. If the perpetrator is the supervisor or clinical instructor, the targeted nurse should write a detailed letter to the supervisor or administrator that explains the events of bullying behaviors and provides meeting dates with leadership and HR.
Confrontation is challenging, and the support of management and HR is vital as leaders handle the different processes. Managers play an important role in ensuring a safe work environment, identifying and addressing inappropriate behavior, meeting formally with perpetrators, and distributing organizational policies. Nurse managers also serve as role models to hold staff members to the appropriate workplace behaviors, ethics, and organizational policies. Any deviations by staff should be addressed immediately. A key component of this is that managers pursue all accounts of workplace bullying seriously.
A looming concern in healthcare is the threat of a lawsuit, which can be very expensive. Ensuring adequate interventions took place with properly documented evidence offers an additional level of security. Conversations with perpetrators should be documented using disciplinary action forms to detail meeting specifics, policies reviewed and discussed, and expectations moving forward. These negative behaviors must also be documented on their annual performance evaluation.
Supervisors must understand all the ramifications of workplace bullying for the staff, culture, morale, and teamwork within a unit, as well as the high financial cost of hiring and training another nurse. Successful managers utilize a variety of resources and strategies, including intentional rounding, the process of engaging unit staff, and asking purposeful questions. If a manager identifies individuals who are not performing to the standards of the code of conduct, safe work environment, or zero-tolerance bullying policies, those perpetrators must be confronted without waiting for a victim to come forward.
Intentional rounding can give a manager first-hand visualization of any covert or overt behaviors and provide opportunities for direct communication with staff in an informal setting. As such, an open-door policy is vital for staff to feel comfortable seeking a manager's intervention regarding workplace bullying.
Additionally, strategies to address inappropriate behaviors can be taught, and educational programs must include all employee levels from staff to managers. The education must target resources, strategies of role modeling appropriate behaviors, intentional rounding, and mentoring programs. Educational sessions can be created, and attendance made mandatory. In these sessions, staff members can be informed as a group about the manager's expectations regarding workplace incivility and bullying.13
Similarly, managers can implement mentoring programs, which provide newer staff members with immediate assistance, reinforcement, and wisdom as they transition into the unit. Mentors provide additional support for nurses at all levels. Mentoring programs have also been successful in training nurses to become leaders, improving team and unit morale, and increasing retention.1
Mentoring provides additional support for new nurses to grow personally and professionally. Typically, experienced nurse mentors serve as additional role models for appropriate professional behavior and communication for new nurses. They tend to think out loud and display open-mindedness, inquisitive behavior, goal-setting, and practice debriefing as tools. As such, clinical and educational nurse specialists serve in valuable roles.
Nurses caring for nurses
Nurses can make a difference in eliminating workplace bullying by supporting each other. Beginning with defining, understanding, and developing strategies to address incivility, nurses can reform a hostile and negative work environment into a healthy workplace. Our profession can set the foundation and expectations by standing united and declaring a new motto: “Nurses caring for nurses.”
Coming to terms with bullying2-4
Various terms associated with workplace incivility have been used, often interchangeably. Using the following terms helps nurses precisely identify, acknowledge, and address bullying and incivility behaviors.
- Bullying: covert or overt acts, actions, and behaviors that are intentionally abusive, demeaning, intimidating, and repeated over a period of at least 6 months, which interfere with other staff members' ability to complete their work
- Hostile workplace: an aggressive, unproductive, or otherwise oppressive atmosphere that interferes with a person's ability to function at work
- Incivility: rude, impolite, and/or discourteous behaviors or acts
- Lateral violence: confrontational behaviors that are repeated over time by a peer at the same work level
- Vertical violence: confrontational behaviors that are repeated over time by a supervisor or manager targeting a subordinate employee
Bullying behaviors in the workplace5,6,8,12,13
- eye rolls
- making faces
- excessive monitoring
- ignoring, not listening, turning away, or not responding to questions
- assigning higher workloads or more weekend shifts
- taking credit for others' work
- withholding key patient information.
- belittling communication
- open criticism
- exclusion from social events
- gossip and backstabbing
- mobbing or group attacks
- offensive insults or jokes
- failing to respect others.