By Debra Wood, RN, contributor
July 1, 2011 - At first the concept of nurse bullying seems oxymoronic. The thought of caring professionals acting aggressively toward their peers seems counterintuitive. However, studies show more than a quarter of nurses surveyed report being bullied at work, by supervisors as well as peers.
Cheryl Dellasega, Ph.D., CRNP, wrote When Nurses Hurt Nurses
to raise awareness about bullying behaviors. Photo credit: Stuart Leask.
“It’s relational aggression, and that’s using behaviors to aggress against another person,” said Cheryl Dellasega, Ph.D., CRNP, author of When Nurses Hurt Nurses: Recognizing and Overcoming the Cycle of Bullying, published in June 2011 by the Honor Society of Nursing, Sigma Theta Tau International, and a professor of humanities in the College of Medicine and professor of women's studies at Pennsylvania State University in Hershey. “It’s anything that humiliates, intimidates or manipulates someone.”
Examples include no one helping a nurse who’s not liked, going to lunch and excluding someone, gossiping and saying negative things about each other, or telling someone in front of others what a terrible job she did with that patient.
Shellie R. Simons, Ph.D., RN, added that behaviors may be covert, such as withholding information, rolling eyes or pointing fingers.
Dellasega voiced concern that nurse bullying can result in medical errors, and personal and interpersonal conflict.
June Marshall, DNP, RN, NEA-BC, director of advancing professional nursing practice at Texas Health Presbyterian Hospital Dallas, added that bullying also leads to absenteeism, volatile workplace relationships, stress reactions, and, ultimately, high turnover rates, at a time the profession faces serious shortages.
June Marshall, DNP, RN, NEA-BC, director of advancing professional nursing practice at Texas Health Dallas.
“The motivation for bullying has much to do with having power and control over the victim,” Marshall added.
How prevalent is bullying?
Susan L. Johnson, MN, RN, a Ph.D. candidate in the school of nursing at the University of Washington in Tacoma and a National Institute for Occupational Safety and Health trainee, reported in a 2009 article in the Journal of Nursing Administration that 27.3 percent of nurses responding to a survey of emergency department nurses had experienced workplace bullying in the past six months.
Cole Edmonson, DNP, RN, FACHE, NEA-BC, said Texas Health Dallas empowers the direct care staff to be the keepers of the professional work environments on their units.
Simons reported in a 2010 AAOHN Journal article that 31 percent of the newly licensed nurses she surveyed reported bullying. Her research indicated when a physician bullies a nurse, the nurse, in turn, often bullies a fellow nurse.
“We cannot react to the aggressor, so we react laterally,” Simons said.
Cole Edmonson, DNP, RN, FACHE, NEA-BC, chief nursing officer and vice president of patient care at Texas Health Dallas, reported that 70 percent of the nurses he talks with during orientation indicate they had experienced horizontal violence from a peer.
Bullying is not relegated to informal leaders on a unit. The nurse manager or charge nurse may act as a bully, playing favorites when it comes to assignments or time off.
“If they are role modeling this stuff, it will be worse among the staff,” Dellasega said. “If they get the message that it’s OK to treat people like this, everybody will.”
Dellasega said bullying is more common among women. It happens more often in the hospital setting, because nurses are under pressure and have a limited ability to get away from the stressors.
Anna Maravelas, MA, founder of Thera Rising in St. Paul, Minn., added that nurses often bully as a result of continual and significant change in health care and increased demands on staff. But bullying also occurs in other workplaces.
“It’s an issue that crosses every industry,” said Maravelas, adding that 97 percent of the time the way work is designed contributes more than the people involved.
Johnson suspects that bullying has to do with the culture of management in the United States. People typically accept bullying, just as they did sexual harassment more than 30 years ago, she added.
“We need to start changing the dialogue and manage in a kinder way,” Johnson said.
Therapist Simon Casey, Ph.D., CADACII, founder of Emotional Mastery International in San Clemente, Calif., has found that the mindset of the facility and acceptance of the behavior contributes to its continuance, and that education has to begin in nursing school.
To change the environment, “there has to be motivation on the part of the individuals as well as the manager and institution, but for so long, it has been easier to stay with the status quo and not do anything to address the situation,” Dellasega said.
But that can lead to problems for the unit and for patients.
Preventing becoming a victim
Nurses often accept bullying as part of the job, Casey said. He has found nurses are caretakers and often are co-dependent, and that contributes to their tendency to put up with being the brunt of workplace abuse.
Raising awareness about the problem and taking a self-assessment of interactions are good first steps in helping to end bullying.
“First, we have to recognize that bullying is not a normal behavior in any setting or by anyone,” Edmonson said. “Secondly, it has to be directly confronted by the person being bullied, but at a minimum, it must be reported so any immediate violence can swiftly be dealt with. Nurse leaders can support this by establishing zero tolerance for horizontal violence on their units, and role modeling the behavior; CNOs can establish the same in the organization.”
Texas Health Dallas provides a nurse advocate who nurses can contact about any distressing situation, including bullying.
Simons considers that sort of impartial intermediary important in reducing bullying.
For an isolated incident, Dellasega recommends asking the bully if he or she is having a bad day, but for repeated attacks, she suggests confronting the aggressor in neutral language off the unit, perhaps asking if you had done something to offend the bully and sharing examples of behaviors that hurt or humiliated.
“The bully might not even be aware that those things were hurtful or demeaning,” Dellasega said.
Simons’ research found that nurses were afraid to confront the bully and thought it might make the situation worse, and supervisors told them to let it roll off their backs. Consequently, the nurses left the unit.
Casey firmly believes the nurse must confront the bully, express his or her feelings without blaming, and if that does not work, to take it to the next level of management. He also suggested healthy coping, such as talking with people, taking a yoga class or doing something else to relieve the tension.
Changing the unit culture
“There is an individual decision people make and a collective decision the organization makes—the direction toward bullying and scapegoating [or] one toward cohesiveness and bonding,” Maravelas said. “The good news is I believe people want to be in a positive environment and be connected.”
Achieving that requires addressing processes that might contribute, the structure of the work and the leadership, she said.
“People will reciprocate each other’s behavior with 96 percent reliability,” Maravelas said. “Both negative and positive cultures are contagious.”
Nurse leaders must establish clear guidelines about what behaviors will be tolerated and what is unacceptable, Dellasega said. She also recommended creating a suggestion box, so nurses can anonymously report things that happen on the unit, and asking for feedback about what would make the environment better.
Simon has found the bully is often a highly competent, valuable nurse that administration does not want to lose.
Leadership consultant Gabriela Cora, MD, MBA, takes a harder stand, saying administration should have zero tolerance for bullying behavior.
Lay a plan for improvement,” Cora added. “Reward them when they improve their behavior and be ready to fire them if they continue the bullying behavior. Second, avoid praising or rewarding nurses for their work performance if they are bullies. Instead, respectful treatment to patients and positive interactions with colleagues should be rewarded.”
Maravelas said that handing people a code of conduct does not lead to changed behavior. She recommended letting the group take an inventory about what they think is harmful behavior, then prioritize and self-prescribe changes.
“The group has an opportunity to take a stand and say ‘We don’t want that anymore,’” Maravelas said.
Bystanders on the unit have the power to diffuse a situation and change things, agreed Dellasega. “They can be proactive and nip things in the bud.”
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