ALTHOUGH CARING FOR others is a foundational aspect of nursing, bullying is prevalent within the profession. After witnessing “insidious cannibalism” that she predicted would destroy the profession, Meissner first described nurses as “eating their young” in 1986.1 Despite this stern warning published more than 30 years ago, uncaring behavior among colleagues remains common in nursing. This article offers strategies to identify bullying behaviors and discusses the prevalence of incivility in the nursing profession with a focus on vertical violence.
Bullying and behaviors
In her recent book, Enough! Eradicate Bullying and Incivility in Healthcare: Strategies for Front Line Leaders, Thompson wrote, “Sometimes the most difficult part of dealing with bullying is identifying it and then taking the first steps to end it.”2 Long-standing behaviors that indicate bullying within the nursing community include incivility, bullying, and vertical or horizontal (or lateral) violence (see Coming to terms with bullying).
Bullying can occur at all levels, and any nurse may become a target for incivility in the workplace. This includes nursing students; nurses new to the unit, organization, or profession; senior nurses; nurse managers; and even nurse leaders. In a review of the literature related to nurse bullying on CINAHL and nurse incivility on Google Scholar, studies mainly addressed nurse-to-nurse incivility such as horizonal or lateral violence. Limited research is available on top-down incivility such as vertical violence between managers and their subordinates. Aggressive behavior by an individual in a position of authority has a demoralizing effect on both the targeted nurse and entire team.3-5
Bullying behaviors are best described as actions that demoralize individuals or groups.3 These actions may range from annoying to emotionally traumatic and correlate to degrees of dysfunction.3 Deliberate attacks intended to demean, intimidate, and/or humiliate include eye rolls, public ridicule, and demeaning outbursts.3,6,7
Bullying behaviors can be overt or covert. Overt behaviors are openly hostile, while covert behaviors are more discreet and difficult to prove.8 Nurse leaders engaged in discreet or covert bullying behaviors may resort to withholding pertinent information, assigning work beneath an employee's ability, and ignoring incivility from the other staff. Managers who escalate their tactics to include overt bullying behaviors may use dysfunctional management styles such as emphasizing staff weaknesses, demonstrating an openly disrespectful attitude, fostering public scorn, assigning blame and derision, and implementing social isolation.3
Case in point
Rose has 15 years of experience as a nurse, including 5 years in a postanesthesia care unit (PACU). She was recently hired to work in the PACU at a suburban hospital. During her interview with the manager and the director, Rose expressed confidence that she could meet the outlined expectations of the job, and her orientation progressed without incident. Despite this, she was not allowed to take a full assignment. Within a month, the staff began refusing her offers to help; openly critiquing her work at her patients' bedsides; and redoing tasks she had already completed, such as taking vital signs, assessing pain, and applying warm blankets.
Despite no instances of inadequate or unsafe care, her manager expressed disappointment with Rose and began excluding her from group conversations, avoiding eye contact, and refusing to acknowledge her contributions. Additionally, Rose was not assigned any on-call time. This became apparent to her fellow nurses, some of whom remarked about the unfair scheduling. Despite this, Rose continued to provide appropriate patient care, demonstrate professional behavior, and meet unit time goals. She also volunteered to take extra shifts on the schedule, but the requests were denied.
Rose's manager was new to the PACU. Nurses who had been there longer noticed the bullying behavior and encouraged Rose to hang in there. She believed working hard and remaining positive would be effective. She also initiated in-office discussions with her manager about how to improve. The manager responded with statements such as, “You can't learn in a few months what took me 10 years to learn in the ICU” and “We are too busy to mentor you.”
Five months after her date of hire, Rose was called into a meeting with her manager and unit director. She was given a performance improvement plan, accused of not being up to speed, and encouraged to find another job. She also met and spoke with a representative from the human resources department, who made no suggestions and offered no assistance.
Rose later commented, “My manager did not like me early on, but that should not be a professional issue. She would talk to the other nurses but rarely include me. In my time as a nurse at several hospitals, I have never faced such a situation.”
Simply put, managers can be bullies too. A study from the Workplace Bullying Institute found that more than 60% of participants had experienced incivility from a superior.9 Those experiencing bullying behaviors must be able to recognize and name them immediately. Rose waited 3 months to discuss her situation with her manager.
Many organizations have a zero-tolerance policy to prevent and eliminate bullying and incivility.3 However, one 2018 study noted that employers are typically better equipped to manage the negative effects of bullying with policies and progressive discipline than they are to prevent these behaviors.10 Healthcare organizations, including the human resources department, often find that their practices are inadequate for these situations and may not be supportive of the victims of bullying.10
According to the American Nurses Association, “bullying, harassment, intimidation, manipulation, threats, or violence are always morally unacceptable behaviors.”11 As such, all instances of bullying and incivility should be reported, and nurses must work together to protect one another and create bully-free environments.2 Success has already been reported due to techniques such as:12
- emotional intelligence, which helps to limit emotional response by utilizing behaviors such as self-awareness and regulation, social awareness, and relationship management.13-15
- cognitive restructuring, which uses established communication practices, such as CUS (concerned, uncomfortable, safety) and DESC (describe, explain, state the desired change, consequences), to confront incivility.16
- peer-coaching, which incorporates interventions such as professional accountability programs to de-escalate instances of bullying.17
Every bullying situation is unique to the life experiences, education, socialization, personalities, and goals of the individuals involved. To address problems, healthcare organizations must first recognize and accept that managers may be bullying their staff. Effective antibullying strategies include the following:
Documentation. Nurses who experience or witness bullying behavior should document what was said or done, as well as the date, time, and staff present. Witnesses may be hesitant to speak up out of fear of retaliation, and even those who offer quiet support may be afraid to put their jobs in jeopardy. Documenting the situation will support the allegations as they move through the human resources department and up the chain of command.18 Nurses should also become familiar with their organization's harassment policy.
Conversation. Many healthcare organizations have established processes to report bullying through the chain of command, which may require targeted nurses to address their manager directly.19,20 Nurses must be able to initiate difficult conversations that are direct and assertive but good-natured to address any ongoing issues.21 Targeted nurses should arrange a meeting with their manager and initiate a conversation on the specific instances of incivility using “I” statements.18 For example, the affected nurse might say, “I feel attacked and bullied when you criticize me in a loud voice at the nurse's station.” Follow these comments by suggesting an acceptable behavior, such as “I would find it more helpful if you would ask to speak with me privately.”
Bullied nurses should come prepared and confront the problematic behavior rather than the individual.2,18 If nurses are unable to speak with their manager directly, or if the manager does not respond positively to the discussion, they should communicate their concerns up the chain of command to the manager's supervisor or to human resources.22
Preservation. If the situation does not improve despite being given time, strategic effort, and action, another option for affected nurses is to transfer to a different unit with a work culture congruent with their personality and leadership expectations.
Prevention. When interviewing for a position, nurses can assess the unit to determine whether they will be entering a healthy work environment. Asking about unit turnover rates may reveal indicators of poor leadership or an unhealthy work culture.
The American Association of Critical-Care Nurses established six essential standards for creating and sustaining a healthy work environment:23
- skilled communication
- true collaboration
- effective decision-making
- appropriate staffing
- meaningful recognition
- authentic leadership.
Each standard is supported with evidence-based practices designed to create “work and healthcare environments that are safe, healing, humane, and respectful of the rights, responsibilities, needs, and contributions of all people—including patients, their families, nurses, and other health care professionals.”23
Bullying can negatively affect individuals, staff, patients, and the organization.2 It is a destructive behavior that does not belong in nursing. All nurses have the ability and responsibility to model respectful behavior and speak out against incivility. By advocating for trustworthy resources, such as antibullying teams or reporting hotlines, nurses can help find successful solutions for ending incivility and bullying.24
Coming to terms with bullying8,25-27
Various terms are associated with workplace bullying, and the following may help nurses precisely identify, acknowledge, and address the associated 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
- Horizontal or 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.
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