Our Own Worst Enemies

Abstract

Nurse bullying is a systemic, pervasive problem that begins well before nursing school and continues throughout a nurse's career. A significant percentage of nurses leave their first job due to the negative behaviors of their coworkers, and bullying is likely to exacerbate the growing nurse shortage. A bullying culture contributes to a poor nurse work environment, increased risk to patients, lower Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores, and greater nurse turnover, which costs the average hospital $4 million to $7 million a year. Addressing nurse bullying begins with acknowledging the problem, raising awareness, mitigating contributing factors, and creating and enforcing a strong antibullying policy. Nurses and stakeholders also must actively work to change the culture, and understand that bullying has no place in the nursing profession or anywhere else in health care.

NURSES in the profession call it “eating our young.” Some consider it ingrained in the culture, a rite of passage, or an unavoidable fact of a nurse's life. But no matter how it is explained away, nurse bullying takes a heavy toll. “To name a thing is to take its power away.”1 Bullying is a targeted and destructive behavior that must be called what it is in order to address and eliminate in one of the most caring professions.

The nurse bullying phenomenon is well-documented in the clinical and leadership literature. It starts early and is present from the classroom to the bedside to the boardroom. One study showed that over a 6-month period, 78% of students experienced bullying in nursing school.2 In another study, over half of nursing students reported seeing or experiencing nurse-on-nurse bullying during their clinical rotations.3 Within the first 6 months, 60% of nurses leave their first job due to the behavior of their coworkers.2

Nurse bullying occurs in almost all care settings and units, from the patient floor to the executive suite. In fact, 60% of nurse managers, directors, and executives in one 2018 study4 said they experienced bullying in the workplace, and 26% considered the bullying “severe.”

This article discusses the forms and perpetrators of nurse bullying, and factors that contribute to it. It also examines why bullying is such a pressing problem for health care organizations, how it can affect their clinical and financial outcomes, and strategies for addressing it.

WHAT DOES NURSE BULLYING LOOK LIKE?

Also known as horizontal hostility, relational aggression, and lateral violence, the American Nurses Association defines nurse bullying as “repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient,” calling it “a very serious issue that threatens patient safety, RN safety and the nursing profession as a whole.”5

Bullying can run the gamut from incivility and exclusion to physical violence and death threats. It is important to realize the problem occurs along a continuum that can escalate when not addressed. While there are too many acts of bullying to list here, they can be roughly divided into overt and covert behaviors.

Overt bullying is easier to recognize, and includes techniques like extreme micromanaging, verbal criticism, name-calling, insults, and direct threats. Covert bullying is indirect and passive-aggressive, and can include rumors and gossip, withholding information, unfair assignments, low grades or undesirable tasks as punishment, and sabotage. Microaggressions—brief and commonplace indignities denigrating a person's race, religion, or membership in another marginalized group—are also considered a form of covert bullying.

In the digital world, social media, text messaging, online forums, and even video games have expanded the scope of all bullying. This includes direct harassment as well as indirect harm. In her seminal book, Ending Nurse-to-Nurse Hostility, now in its second edition, author Kathleen Bartholomew, RN, MN, cites examples of indirect cyberbullying, where nurses are shown derogatory comments and posts about them in private text threads and online groups.6

Even if the person does not intend the comment to be seen, or deletes it moments later, there is no stopping others from taking a screenshot and sending it to the target, often with good intentions. The ease and immediacy of digital media—and the fact that it extends communication beyond the workplace—magnifies the impact of negative behaviors. An offhand remark made in a brief moment of frustration can cause great damage when it is communicated in a digital form. In addition, we have learned that social media promotes passive-aggressive and anonymous bullying toward individuals and groups.

WHO IS DOING THE BULLYING?

While it is true that some older nurses pick on their younger colleagues, bullying behavior transcends age, gender, and experience level.7 Younger nurses might criticize their elders’ appearance or physical limitations. Older nurses may take advantage of younger colleagues’ lack of experience or unfamiliarity with minor elements of the job. Male nurses can bully female nurses, registered nurses (RNs) mistreat licensed practical nurses (LPNs), and vice versa. Those in certain specialties and units have been known to gang up on nurses in other departments. And of course, there is always one-on-one harassment, and bullying for no discernible reason. The most frequent bully of nurses is other nurses.8 A list of common nurse bully archetypes appears in Table 1.

Table 1. Common Nurse Bully Archetypes^a.

The supernurse is often more experienced or specialized than most, and communicates a sense of superiority through an elitist attitude, condescending manner, and “corrective comments.”

The resentful nurse develops and holds grudges, encourages others to “gang up” on the transgressor, and tends to create drama that can permeate the work environment.

The PGR nurse uses put-downs, gossip, and rumors (PGR) to bully other nurses, and is often quick to take offense to a neutral remark.

The backstabbing nurse is “two-faced,” cultivating friendships that they then betray, using information as a weapon to enhance their power.

The green-with-envy nurse expresses bitterness to those who have what they do not: looks, status, personality, possessions. Their victims often do not realize they are a target.

The cliquish nurse uses exclusion as a means of aggression, showing favoritism to some while ignoring others

^aReprinted from American Nurses Association5 and Dellasega.23 Used with permission.

Bullies often lack self-confidence and may see certain colleagues as threats. Some may worry about younger nurses usurping their place in the hierarchy, and others can feel threatened by their elders’ competence and experience. Often, this is a learned behavior from early childhood, or a transmuted behavior in victims of bullying, who become bullies for self-protection.

Personality traits also play a role. Anxiety, anger, and vengefulness make it more likely that someone will become a bully, but these traits are not exclusive to nurses. The three primary roles of bully (perpetrator), victim (target), and bystander (witness) must each be examined closely in every situation. In a bullying environment, cliques can form, and scapegoats and favorites emerge. Some nurses will become bystanders, some will learn to ignore the problem, and some will become bullies themselves—perpetuating the toxic cycle. The ultimate goal is to change the bullies’ behavior, strengthen and support victims, and turn bystanders into upstanders.1

Workplace bullying also requires the right environment to thrive. The quality of leadership, in the unit and in the organization, can contribute to a bullying culture. Supervisors and managers who lead by intimidation and fear tend to foster the same in their staff. Nurses in management or middle management occupy some of the highest-pressure positions in health care, and this pressure comes from every direction. In many organizations, a lack of authority coupled with a high level of accountability makes the individuals in these positions feel somewhat powerless. Nurses in management roles often adopt a leadership style modeled on bad bosses in the past, which tends to intensify under pressure. When bullying becomes part of the culture at an organization, these behaviors tend to persist, even as individual nurses come and go.

While nurse leaders encounter bullying and incivility, their experience does not directly mirror that of clinical nurses. Exploring the uniqueness of the bullying experience among nurse leaders, Edmonson9 found they experience moral distress when they know the right thing to do, but are prevented from doing it due to organizational factors. Nurse leaders, like clinical nurses, have little formal training in ethics and are challenged to frame experiences like bullying in an ethical framework, and then to act. Nurse leaders, including executive nurses, also experience bullying from those who are perceived as higher in the authority gradient, including executives in operations and finance, medical staff, and so on. The bullying nurse leaders’ experience can take the form of directives that may create safety situations for staff and patients, lack of support for the primary mission of the organization (patient care), and even exclusion bullying—being intentionally left out of critical decisions.

NURSE BULLYING CULTURE AND THE “2030 PROBLEM”

Bullying is more likely to occur in high-stress settings with high-stakes outcomes, heavy workloads, and low job autonomy—all part and parcel of the nursing profession and health care in general. As if the job were not stressful enough, a concatenation of circumstances is bringing new pressures to the patient care industry.

The Baby Boomer generation of adults born between 1946 and 1964 is one of the largest and unhealthiest populations in US history. By 2030, there will be a 73% increase in the number of Americans older than 65 years. Half of them will be affected by chronic disease, which accounts for over 80% of hospital admissions.10

At the same time, the current and future nursing shortage is accelerating the 2030 problem. The average age of a registered nurse is now 50 years, and the average nurse is 30 years old when they enter the profession.11 A third of today's nursing workforce will likely retire in the next 10 to 15 years. Nursing school faculty is also on the decline,12 limiting the number of enrollees schools can handle and decreasing the overall quality of their programs.13 A good percentage of nurses end up dropping out before retirement age—turnover rates range from 8.8% to 37% depending on the state.13

Some of this can be attributed to family and child-rearing, as in any female-dominated profession. Nursing is not for everyone. It is physically and mentally demanding, with long hours over weekends and holidays. It has been called the most dangerous profession, not only from a workplace violence perspective, but also because of an alarming rate of back injuries due to lack of teamwork, limited resources, and lack of equipment and training.

But even nurses who love their jobs, and who are able to handle the physical and mental demands, can be driven out by a toxic work environment. Unlike the “silver tsunami” of aging Baby Boomer patients, bullying-related nurse attrition is a complex but highly controllable factor. Addressing the problem requires total commitment at every point in the health care ecosystem, from the individual level to the organizational, including policy and advocacy for prevention.

BULLYING AND THE BOTTOM LINE

Even if the “2030 problem” is not yet on everyone's radar, nurse bullying can have serious implications for an organization. Even in well-staffed hospitals, the presence of a bullying culture may be contributing to poorer outcomes across the board.14

Patient satisfaction scores are directly tied to Medicare reimbursement and hospital reputation. Nursing satisfaction is tied to these scores. According to a 2009 study commissioned by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS),15 “The nurse work environment was significantly related to all HCAHPS patient satisfaction measures. Additionally, patient-to-nurse workloads were significantly associated with patients’ ratings and recommendation of the hospital to others, and with their satisfaction with the receipt of discharge information.”

This study was the first to explore in detail what many already suspected: that unhappy nurses can create dissatisfied patients.

The report goes onto say: “Improving nurses’ work environments ... may improve the patient experience and quality of care.” A better nurse work environment has also been linked to lower risks of death and better outcomes for patients.15

A 2008 study of 511 randomly selected Massachusetts RNs found that bullying impacted job satisfaction even more than salary.16 This and other research shows workplace incivility is strongly linked to burnout and job dissatisfaction. Nurses experiencing this often make plans to leave their jobs,16 and when they do, the cost can be high.

THE HIGH PRICE OF NURSE BURNOUT

In 2018, the average cost of turnover for a bedside RN ranged from $38 000 to $61 100, with the average hospital losing $4.4 million to $7 million.17 Each percentage change in RN turnover will cost—or save—the average hospital an additional $337 500.17

Multiple studies have shown that up to 34% of nurses18 leave or consider leaving the profession as a result of bullying. And even if they stay, the fallout from bullying behaviors—including absenteeism, decreased productivity, and medical and legal expenditures—costs US health care organizations an average of $11 581 per nurse per year.19

Financial outcomes aside, a bullying culture is bad for physical and emotional health. Nurse bullying has been linked to psychosomatic symptoms such as headaches and frequent illness, depression and anxiety, reduced productivity, absenteeism and fear of going to work, impaired relationships, poor quality of life, and suicide.20 These comorbidities prevent many nurses from bringing their best to work. Bullying can decrease quality of care and collaboration. It denigrates the profession and the organization. At the very worst, it could threaten patient safety, as patients are at the end of the decisions made by nurses and other clinicians.

Other hidden and indirect costs must be considered. Bullying sacrifices an organization's ability to achieve consistent, high-quality outcomes associated with high reliability science. It is not possible to achieve the goal of high reliability in health care in environment that permits or promotes bullying. The defining characteristics of a highly reliable organization include healthy work environments, emotional and physical safety, and a culture that is “just,” where it is safe and expected to speak up.

Nurses invest years of time and often thousands of dollars into their education and training. But 43% of newly licensed nurses leave their first jobs within the first 3 years.21 Where are they going? Possibly to health care organizations that put an emphasis on a positive work environment, and take a stand against bullying and incivility. Many nurses work toward career destinations other than the bedside. In this emerging paradigm, a nurse completes 3 to 5 years of bedside clinical practice before changing positions to advance practice, leadership, education, or other roles.

Nurse bullying is a pervasive, systemic problem that will not disappear overnight. But it has no place in the nursing profession. Bullying needs to be addressed in nursing schools and at every point on in a nurse's career. Table 2 contains a list of strategies organizations may consider implementing to address nurse bullying.

Table 2. Strategies for Addressing Nurse Bullying.

1. Admit there is a problem. Bullying will thrive so long as no one speaks about it, and even if you do not think it is going on at your organization, it could crop up at any time. Nurse bullying is a systemic issue in the profession, and every workplace is at risk.

2. If possible, eliminate any situational factors that may make bullying worse, such as work overload. Stress and fatigue can bring out the worst in people.

3. Start at the top. Train leaders in clear communication and collaboration skills. Make sure they are modeling the behaviors they expect their employees to follow.

4. Commit to a zero-tolerance policy for those bullies or bad actors who do not change. Name the specific behaviors included in your definition of bullying so that all staff members are clear on the expectations. Ensure there are policies in place detailing how bullying should be reported and addressed.

5. Foster a respectful environment where nurses feel comfortable reporting acts of bullying to their leaders, or feel supported to address it directly themselves. Take all reports of bullying seriously and respond to them quickly. Be clear with people who report bullying that you believe them, first and foremost.

6. Address bullying behaviors as they happen, in a firm but not accusatory manner. Take a systems approach, bringing Human Resources into the situation early and often.

7. Encourage nurses to seek behavioral health services if needed. Workplace bullying can seriously impact a person's mental and physical health.

8. Include coworker incivility in your social and online media policy. Make it clear you will not tolerate any personal attacks on fellow staff, in person or online.

9. Encourage nurses to hold each other accountable. There are often more bystanders than bullies, so empowering nurses to call out bullying behaviors can change the culture from the inside out.

All stakeholders, from school faculty to hospital administration to nurses themselves, need to work together to create a safe, positive environment for nurses to reach their full potential. In the words of workplace bullying expert Dr Renee Thompson, “If we are going to finally eliminate bullying and incivility, we all need to do our part.”22