“There is no need to try to make me feel inadequate, we are on the same team“.
This was the initial response from the most daring of new-graduate nurses to come through our ICU since I had joined the ranks. I had only been working as an RN for about 6 months and knew the drill. When the night shift nurses came on for report, you could expect a grilling about every last detail of your patient followed by admonishments, second-guessing, over-the-top interrogation, a few “gotcha’s” and plenty of eye rolling. It was hard to tell as a new graduate nurse whether shift report followed by a room inspection was appropriate or not. After all, bedside report has been promoted as a safety and continuity of care approach recently. However, intimidation, poor teamwork, gossip, and pure bullying were also a big part of the experience for new nurses. Although our unit had only a small number of nurses engaging in this behavior it made me wonder what other nurse’s experiences were like.
Having been in healthcare for over 10 years and being given the opportunity of attending graduate school, bedside nursing is no longer a part of my daily routine at work. However, my curiosity surrounding nurse bullying has grown as I speak to nursing students about their fears regarding entering practice. Work place incivility has taken a new role in the spotlight as an overarching issue that affects not only new nurses but veterans as well. The problem has escalated to the point that in 2008 the Joint Commission issued a standard on intimidating and disruptive behaviors at work, citing concerns about patient care:
“Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team (Joint Commission, 2008).”
If the Joint Commission becomes involved, it is apparent that a significant problem exists. For years, nurse bullying had been a silent issue that flew under the radar. Nurses assumed that all professions experienced the phenomenon of “eating their young”. Only with renewed focus on health care standards and containment of the costs of recruiting and training new nurses has the problem garnered new attention.
Bullying is the repeated and habitual use of force, threat, or coercion to abuse, intimidate, or aggressively dominate others. The reason that nurses tend to bully one another is complicated. Despite our large workforce numbers, nurses can be seen as an oppressed group within the hierarchy of the hospital. Lateral violence takes place when nurses feel frustrated and unable to verbalize concerns to superiors for fear of punishment. Sound familiar? Often times, questioning physicians or supervisors within a strict practice model is met with opposition. The inability to express feelings and concerns diminishes nurses’ self-esteem and fosters powerlessness. In order to boost self-esteem, some nurses act out against other nurses because of lack of control over their own situation. This, in turn, triggers the negative cycle which continues ad infinitum.
The toll on healthcare quality is immense. With high nurse turnover, hospital staffing becomes a challenge and consistent training is threatened. Studies estimate that 44% to 85% of nurses are victims of nurse bullying and up to 93% of nurses report witnessing lateral violence in the workplace (Jacobs & Kyzer, 2010; Quine, 2001). In fact, one in three new graduate nurses considers quitting nursing altogether because of abusive or humiliating encounters (Townsend, 2012).
High staff turnover, absenteeism, poor performance, and patient safety issues related to inadequate teamwork and communication are preventable problems that can be attenuated with a sound approach to work place incivility. The College of Physicians and Surgeons of Ontario and the Vanderbilt group (College of Ontario, 2008) have developed evidence-based suggestions to ameliorate workplace bullying:
- Making expectations explicit by having a code of conduct supported by appropriate policies
- Ensuring robust Board support for clinical leaders in implementation
- Support and training for those dealing with disruptive and intimidating behavior
- Screening for health and personal issues
- Proactive surveillance systems
- Dealing consistently and transparently with infringements
- Dealing with lower level aberrant behavior early
- Having a graduated set of responses (informal, formal, disciplinary, regulatory) depending on the severity of the incident
- Making resources available to help those displaying and those affected by disruptive and intimidating behavior
Although it may appear that some nurses take self-righteous pleasure in other nurse’s mistakes, it is important to be assertive with co-workers rather than passive-aggressive. Own your mistakes. You will make many of them. We all do. Be humble, but also hold other people accountable for how they speak to you and treat you. Don’t be afraid to have a professional conversation with someone who is being inappropriate. We all fear conflict but you will have to confront people in a constructive manner. Not just co-workers, doctors, and managers, but patients as well. Most nurses dislike this part of the job but, unfortunately, it must be done. These rare occasions can be a learning opportunity for both the offender and the recipient. Escalating the matter to management is always an option, as well. Workplace bullying can be overcome with both an organizational and personal approach. In order to stop infighting amongst one another, we must advocate for our profession as a whole. Only when nurses feel empowered within the health care model will we see improvement in lateral hostility among our ranks. Until that time, remember what it was like to be a new graduate as you welcome the the next generation of nurses. Strive to undo what may have been done to you and “be the change that you wish to see in the world.”
Jacobs, D., & Kyzer, S. (2010). Upstate AHEC lateral violence among nurses project. South Carolina Nurse, 17(1), 1.
Quine, L. (2001). Workplace bullying in nurses. Journal of Health Psychology, 6(1), 73-84.
Townsend, T. (2012) Break the Bullying Cycle. American Nurse Today.
College of Physicians and Surgeons of Ontario: Guidebook for managing disruptive physician behavior. Toronto, 2008, http://www.cpso.on.ca/uploadedFiles/downloads/cpsodocuments/policies/positions/CPSO%20DPBI%20Guidebook(1).pdf
Joint Commission: Behaviors that undermine a culture of safety. Sentinel Event Alert, July 9,2008:40, http://www.jointcommission.org/sentinel_event_alert_issue_40_behaviors_that_undermine_a_culture_of_safety/