Bullying, incivility, and workplace violence are pervasive problems within the nursing profession, resulting in a toxic work environment, a variety of related health issues, increased costs to healthcare organizations, and compromises in patient safety. Bullying, incivility, and workplace violence can occur in all areas of nursing.1 Each of these pervasive challenges can take many forms. Here are a few illustrative scenarios:
A new RN is struggling with his patient assignment. When he requests help from his more experienced coworker, she replies that she is “too busy” with her own assignment to assist, even though she knows he has been struggling. Her denial of assistance is accompanied by a comment such as, “I am just as busy as you are. Keep trying, and you will eventually figure it out. That's how I learned when I was a new nurse.”
During shift change, an experienced RN rolls her eyes and mutters under her breath as she reads the assignment board that was created by a less-experienced, younger RN for her first time. She comments within earshot of the new nurse, “These Millenials have no idea what they are doing.”
A newly hired RN who was once unlicensed assistive personnel (UAP) has noticed that other RNs on the unit do not seem to trust her judgment and repeatedly tell her what she is doing is wrong. Instead of providing insight into strategies for improved performance, her nurse colleagues simply turn and walk away when she tries to explain why she selected a certain approach.
These examples demonstrate the critical importance for all members of the nursing profession to actively examine and combat the effects of bullying, incivility, and workplace violence in the healthcare environment; establish methods for identification of and disciplinary consequences for bullying behavior; and conduct an examination of the related financial burdens of attrition for hospitals and other healthcare agencies. Nurse manager promotion of zero-tolerance policies for workplace violence, including bullying, and increased education is necessary for a cultural shift within contemporary nursing policy and practice.
Bullying, incivility, and workplace violence defined
Workplace bullying has been discussed in the nursing literature for almost 20 years. The phenomenon is often referenced by the expression “Nurses eat their young.”2 In spite of the widespread recognition of this damaging behavior toward new, young, or inexperienced nurses, the problem persists. One definition of workplace bullying is repeated, health-harming mistreatment of one or more persons by one or more perpetrators. It is abusive conduct (threats, humiliation, intimidation, or verbal abuse) that causes work interference.3
Bullying may also be referred to as horizontal violence, lateral violence, or relational aggression.4 Bullying, abuse, conflict, incivility, and lateral violence of any form make up the broader phenomenon of workplace incivility.5 All of these terms describe forms of psychological and social harassment brought about by one nurse or a group of nurses (also known as “mobbing”) using covert and overt behaviors against another nurse or group of nurses. Mobbing is executed by a leader, who can be a manager, coworker, or subordinate. The leader rallies others into a systematic and frequent moblike behavior toward the victim.6
Covert and overt behaviors
Nonverbal cues, isolation in clinical settings, deliberate withholding of information, gossiping, and sharing private information are some examples of covert behaviors. Other examples include making unfair assignments, refusing to help someone, ignoring others, making faces behind someone's back, refusing to work with certain people, whining, excluding others from information that might impact patient care, and fabricating information that might be embarrassing or defaming.7 Overt or blatant behaviors include scapegoating, sabotaging another nurse, preventing a nurse from doing his or her job (hiding information or items needed for patient care), forming cliques, and using passive-aggressive dynamics toward another nurse.4 Other overt behaviors are name-calling, bickering, fault-finding, criticizing, intimidating, gossiping, shouting, blaming, belittling, and eyebrow raising.
Scope of the problem
Bullying is responsible for both physical (stress-related weight gain or weight loss, hypertension, cardiac palpitations, and irritable bowel syndrome) and psychological (depression, acute anxiety, and posttraumatic stress disorder) issues among nurses.8 Perpetual and excessive conflict leads to higher burnout rates, which impact facilities nationwide as they struggle to decrease attrition rates for RNs. Bullying also negatively affects recruitment and retention of nurses, and is considered one of the causes of the nursing shortage.8 Yildirim noted that 86% of the nurses surveyed faced one or more types of bullying during a 12-month period, and that the sources of many of these behaviors were their managers.9
Bullying can take place in many different types of professional nursing relationships. Lateral bullying encompasses nurse-to-nurse bullying. Bullying can also occur within a chain-of-command line of authority such as physician-to-nurse, administrator/nurse manager-to-nurse, nurse-to-student, or faculty member-to-student.5 One study found that the main source of bullying was from a peer (57%).5 It was also found that clinical nurses (44%) were the main sources of bullying behavior, followed by nurses in positions of leadership (director of nursing, manager, supervisor, charge nurse, nurse preceptor, and/or nurse educator) (19%).5 This particular study noted that 25% reported never being bullied, although 28% reported being bullied by a member of leadership.5 In another study completed by Simons, Stark, and DeMarco, unmanageable workload (71%) and being ignored or excluded (58%) were the most commonly practiced bullying behaviors.10 It was also noted that when senior nurses demonstrate workplace bullying to novice nurses, these behaviors are later perpetuated and therefore become the social norm.5
Hospital financial burden
As of March 2016, healthcare ranked third among the top three industries with high turnover rates. The finding also noted that 43% of newly licensed nurses who work in hospitals leave their jobs within 3 years. Additionally, 33.5% resign after 2 years, and 17.5% work for only 1 year.11
Research has noted that workplace incivility or bullying has increased in frequency and severity in the US.5 In turn, nursing turnover rates can be very costly. For example, the estimated cost to replace one specialty nurse (ICU or surgical) may exceed $145,000.12 Further, in the healthcare environment, workplace incivility has been estimated to cost almost $24 billion annually in the US. Wilson, Diedrich, Phelps, and Choi discussed that in one study sampling of over 230 US healthcare organizations, employers reported spending more than $300,000 per year in budgetary expenditures for every 1% increase in turnover rates.13 This trend is also associated with higher nurse-to-patient ratios and increased risk for compromised patient care.
Another study noted that nurse-to-nurse relationships are a key component that relates to nurses leaving the profession; specifically, participants revealed that those who considered leaving the profession were influenced by poor nurse relationships.14 Additionally, it was not that there is a need to provide enhanced onboarding for new graduates that can enhance good relationships with expert nurses.
Berry and colleagues previously reported that with the anticipated shortage of RNs for 2015, and the 581,500 estimated new RN positions that were being projected at that time, the pervasive occurrence of bullying would have a direct impact on the nursing profession, and, subsequently, attrition rates and patient care.15 One-third of novice nurses who have been bullied intend to leave their current positions. This is especially a problem when experienced nurses, who often engage in bullying, are assigned to precept and provide support for novice nurses. For example, a hostile work environment has been linked to emotional and physical effects that can cost an institution an estimated $30,000 to $100,000 for each nurse per year. It is also twice as likely that a nurse who is bullied will leave his or her current position.5
To address bullying in the workplace and successfully implement zero-tolerance policies, institutions must be dedicated to a culture change and related enforcement within the workplace environment. Policy and procedures guide practice expectations and requirements; subsequently, such culture change regarding refusal to tolerate bullying, incivility, and workplace violence will depend on institutions establishing explicit guidelines outlining the expected codes of conduct and consistently enforcing consequences when the code of conduct is broken. This requires that these policies and procedures must be shared with all employees of the institution, including a formal acknowledgment that these have been reviewed and understood.
Role of the nurse manager
In the healthcare setting, nurse managers play a critically important role in the identification, management, and prevention of bullying. The most significant dynamic is a level of trust that needs to be formed between a clinical nurse and the nurse manager. For example, in one targeted study regarding an understanding of nurse-to-nurse relationships and the impact on work environments, one of the results included participants highlighting that the active role of nurse managers was crucial toward establishing good nurse relations.14
To promote a culture shift that does not tolerate bullying, incivility, or workplace violence, the nurse manager should be easily approachable, and the staff should feel comfortable reporting behaviors without the fear of retaliation. Providing nurses the opportunity to voice their concerns will also benefit the nurse manager, as it can provide a barometer of related behaviors on the unit and also provide awareness of any concerning behavior patterns. The nurse manager can institute huddles or team meetings at the beginning of each shift to discuss the staffs' needs and concerns, which in turn may set in motion strong teamwork, high morale, and effective communication. Nurse managers can also increase awareness of workplace incivility, including a zero-tolerance policy for all employees, by discussing the issue at staff meetings.5
Nurse managers should address bullying, incivility, and workplace violence immediately when reported; this action will gain staff respect, particularly for the nurse who has reported being the target of any of these behaviors. This also promotes an environment where staff feel supported and affirm that this type of behavior will not be tolerated. The bullied employee must be able to expect active listening from the nurse manager, who should seek clarification, and, in early episodes of behavior that has been identified as bullying, act as a mediator regarding the situation.
Nurse managers should complete nurse rounding on their unit. This should also be done on a regular basis on off shifts to show support for all staff. This will allow managers to determine what is happening on their unit, and when he/she is not usually working.5 Recognition of job performance, inclusion of decision-making, and meaningful engagement with staff will enhance job satisfaction.
Bullying, incivility, and workplace violence in nursing can cause physical and emotional health problems for victimized nurses. Bullying can be detrimental in the healthcare environment, regarding both costs and patient safety. Zero tolerance of bullying in nursing should be more than just a slogan. Achieving true cultural change in healthcare will require more than just new policies and procedures; it requires strong leaders to commit to implementing zero-tolerance policies to effectively change the workplace culture. Contemporary nurses should strive to evolve the historic norm “Nurses eat their young,” to “Nurses promote their young.”