The outcome of this article is to educate healthcare professionals in strategies to reduce the frequency and impact of bullying in the workplace setting.
After completing this course, the learner will be able to
Healthcare is a stressful field, even when effective teamwork and interdisciplinary communication are in place. Bullying behaviors may be difficult to detect at first, and managers are prudent not to overreact. However, bullying in healthcare is an increasingly prevalent issue. It can include repeated, health-harming mistreatment ranging from verbal abuse and humiliation to threats, sabotage or worse.1 As evidenced by the recent case in which an anesthesiologist insulted her sedated patient, the media can make headline news out of events that otherwise only garner interest in the break room or hospital cafeteria.2
The term “bullying” conjures images of getting beat up at recess or picked on during gym class. Synonyms in the corporate world include incivility and lateral or horizontal violence. Aggression and violence from patients and visitors is a real threat, but healthcare professionals report hostility from their fellow professionals to be a greater concern. This hostility occurs with greater frequency than sexual harassment or various types of discrimination. Physical violence is rarely part of horizontal violence, which typically consists of bullying from someone with comparable authority. Intimidation, withholding clinical information or assistance, undermining, harassment, and constant criticism are all signs of bullying.1
Bullying is not always verbal. Attacks delivered via task assignment or exclusion to erode professional competence and reputation are also forms of bullying. A bullying interaction involves repeated negative and unreasonable behaviors, often more than once a week, for greater than 6 months.3 The target experiences damage and realizes he or she is being bullied. Many of these interactions involve an imbalance of power, though that power may be social and informal.
Nurses struggle with bullying more than other health professions, and among new nurses, 63% report experiencing workplace bullying.1,3 More than 20% report bullying to be a daily occurrence that affects productivity.1,3
Similar to the experience of novice employees, students and even educators face high potential for bullying. Office or hospital staff may view faculty to lack practical clinical skills, while students have limited rights and access to resources. If they feel entitled to better grades, students may bully professors. Although it is not as common, veteran nurses and physicians report bullying from newer nurses. Thus, bullying is sometimes complex and nuanced rather than clearly intentional. Often, it is not easily remedied by punitive policies directed against a clear aggressor.
A cross-sectional descriptive study examined the prevalence of bullying among faculty members at schools of nursing offering a BSN or higher. It found that 36% of respondents (faculty members) experienced bullying based on the Negative Acts Questionnaire-Revised (NAQ-R). They reported senior faculty and administrators as more likely to be bullies, and a significant correlation was found between meeting frequency and the report of bullying.4,5
Evidence of bullying and incivility in the nursing profession is well documented. Lacking is documentation of this in nurse anesthesia and similar literature about advanced nursing practice, physical therapists, and physician assistants. These practitioners often find themselves “caught in the middle” and bullied by both the physicians and the nurses with whom they must work closely. The implications of such acts can cause physical, emotional and psychological distress within and among practitioners—and potentially toward the patients under their care. Healthcare providers and facilities are becoming increasingly dependent on outcomes and quality of care for reimbursement. Healthcare professionals are an essential component of both of these.
Maintaining a positive work and learning environment may prevent distress among students, and healthcare professionals and potentially promote quality care improvement. Students are especially vulnerable for multiple reasons, including the possibility that evaluations will suffer if they stand up for themselves. In certain circumstances, underreporting of these activities occurs due to lack of confidence in the institution to take action. Others may choose not to report bullying out of fear of retaliation, the fear of seeming petty, or the fear of becoming the target of more abuse if acting as a whistleblower.1
The topic of bullying needs to be explored with those it affects, in order to more fully understand its impact and develop methods to prevent, discuss and deal with bullying situations as they arise. Often, educational and healthcare institutions fail to act on issues of incivility and have limited measures in place to address it.1,6
A healthcare professional who is being bullied won’t function at peak physical and mental health and may even question his or her ability to perform effectively. Nurses must become aware of their surroundings, as well as the internal and external resources available, should they find themselves or a coworker becoming a bullying target. Targets of bullying behavior can experience weight fluctuation, hypertension and angina, pain, headaches, and a litany of psychological effects—from fatigue and anxiety to post-traumatic stress disorder and suicidal thoughts.3
Employees and students may respond to negative feedback by letting it positively affect their practice, or they may withdraw and deflect to protect themselves from introspection and acknowledging the possibility of failure. The effects of bullying are highly individualized and partly depend on the communication skills and emotional intelligence of targets. In this context, emotional intelligence refers to correctly assessing, monitoring and perceiving one’s own emotions and the feelings of those around them to better make decisions and reach goals. Self-control and clear thinking during tense situations reflect high emotional intelligence, but this is affected by the shared emotions and subsequent behaviors in workplace culture. Ethics and decisions are heavily influenced by peer behaviors, but self-monitoring and political skill decrease the incidence of bullying. This is because of empathy more than social capabilities. Leadership is an important facet of emotional intelligence because someone who cares little for others but possesses high emotional intelligence tends to bully and manipulate covertly.5,7
In part, because bullying is often random, many studies don’t find common variables in bullied healthcare workers. However, demanding jobs with little control and social support correlate highly with bullying. Autonomy is an important weapon to fight bullying. A stifling environment challenges communication and leads to errors that may result in a healthcare professional appearing less competent. A common thread is negative affectivity that causes more distress and nervousness than warranted by a situation. Negative affectivity is a personality variable that expresses the experience of negative emotions and poor self-concept. Negative affectivity produces a variety of negative emotions, including anger, contempt, disgust, guilt and fear. Nurses cite external emotional abuse as the most common form of bullying and often rely on support systems at work to deal with the situation. In contrast, secretaries and similar hospital staff seek social support from families and friends outside of work when bullied.8
Some evidence postulates that personality traits such as conscientiousness lead to employees being repeatedly bullied despite job and career changes. People affected by a mental disorder caused by stress are often eligible for compensation. Bullying behavior leading to mental harm may qualify, and as performance decreases, work-related injuries increase. The benefits versus the costs associated with employers taking a proactive approach to bullying are 2:1.3,9 Ignoring behavior is expensive and can affect teamwork by staff ranging from housekeeping to attending physicians. Indirect victims may become an issue. In healthcare, this compromises patient’s safety: patients already are in a vulnerable state. Distraction harms patients.3,9
Attempts to quantify patient harm resulting from bullying reveals startling results. Rather than delays in procuring juice and saltines, studies show that bullying leads to increased patient mortality, wrong site and wrong patient surgery, foreign objects left in surgical wounds, and multiple medication and protocol errors.1
Many managers would agree that bullying is wrong, but they do not realize that it has tangible costs to their workforce. A poll of 800 managers and employees across 17 industries produced some startling statistics. Of those who had been targets of workplace bullying, 66% said their performance decreased, 48% intentionally decreased their work effort, 80% spent work time worrying about the incident, and 25% admitted that they took out their frustrations on customers.10 In healthcare, this could impact patient satisfaction and Press Ganey scores, thereby decreasing public opinion of the institution/system.1,10
The Joint Commission issued a Sentinel Event Alert in 2008 to emphasize that rude, disruptive behavior among healthcare professionals can pose a serious threat to patient safety and overall quality of care. The commission suggested that all accredited programs take action. One recommendation is that all accredited healthcare organizations create behavioral codes of conduct and establish a formal process for managing unacceptable behavior. These codes of conduct should focus on respect, with a zero tolerance for intimidating behavior and a means to alleviate fear and retribution among those who report disruptive behavior.11
Because bullying is complex and skilled perpetrators use the very rules against bullying to intimidate others, zero tolerance policies are not always effective. Effective policing requires transformational or congruent leadership rather than the more common transactional leadership. Improved productivity is the goal of transactional leadership, even if nurses are lured into working harder and longer in exchange for bonuses or overtime pay. Transformational leadership is the most effective leadership approach to improve workplace culture, since it is flexible and fine-tuned to the emotions of others. Congruent leadership fosters collaboration and the ability to resolve tense situations and people diplomatically.5,7
For the most current example of a bullying policy, the authors turned to an ongoing capstone project from Peter Strube, CRNA, of Rosalind Franklin University. He writes: “Anesthesia providers set high standards and expectations for themselves and others. The CRNA must expect and demand excellent behavior across all environments. The healthcare system should strive to maintain a healthy, positive and safe environment for all staff, students and employees. It is important to promote a social climate with social norms that are free of lateral violence, bullying activity, harassment, and intimidation. The healthcare community must subscribe to the philosophy that lateral violence or bullying in any fashion constitutes unacceptable behavior.12”
In 2000, the American Association of Nurse Anesthetists issued a practice statement about promoting safe, healthy work environments. The development of a strong educational program requires training staff members to identify lateral violence and educate them about proper interventions and techniques to deal with it. Strube’s capstone educational module was designed to be integrated as a functional tool to address bullying.12
Bullying in the workplace can lead to physical, mental, social and financial stress for the target. How does one pick up the pieces and move forward after a bullying event? Targets of bullying behavior are not “victims,” because they can change their situation with education and resources that promote healing and wellness. This does not mean they have easy choices. Many targets find themselves self-blaming when in reality they did nothing to provoke the inappropriate behavior and abuse. This self-blame can often trap targets, preventing them from taking steps to end the psychological violence. It can spiral into self-destruction as the target’s self-confidence destroys itself. When self-confidence is lost, the target starts to believe the bully’s lies and becomes more vulnerable to the situation and the bully. 9 The first steps in responding to bullying are awareness and avoidance of self-blame. Once the self-blame ends, targets can focus on healing. Common resources to help regain confidence and have faith in the journey ahead include supports such as family, close friends and colleagues; professional therapists and counselors; legal attorneys specializing in employment law; and organizations such as BEHAVE Wellness (Bully Elimination, Health, Advocacy, Violence Education).9
Workplace employee wellness and human resources departments may not always be beneficial places of support for bullied nurses. An oppressive work culture will extend past the barriers of a nursing floor or unit. Concerns about reporting systems, privacy and equitable treatment are valid, especially if the bully is in management. In some cases, wellness programs sponsored by employers can increase job performance while decreasing compassion fatigue and stress.8,13 Although the authors own a wellness program, programming corporate happiness for employees is far from a complete fix for bullying issues.
The demand for pharmacists, nurses, and other providers is cyclical, and bullying has ebbed and flowed through the decades. Hospitals able to retain and recruit employees are conducive to high autonomy and employee leadership. In its absence, some institutions have turned to wellness models that penalize and simply pass healthcare costs to the employee rather than helping with bullying or any other problems affecting the health of nurses. Although wellness programs are better known for granting rewards for healthy behaviors, as they evolve amidst cost-cutting measures, the end result can be corporate bullying and lower morale.14,15
A bullying target’s path to recovery and wellness is highly individualized. Happiness is an internal feeling, and to find happiness, it must first be defined. According to Amit Sood, MD, MSc, FACP, chairman of Mayo Clinic’s Mind-Body Medicine Initiative, the key to happiness is a healthier way of thinking with our brains. Gratitude practices can bring a sense of contentment, place things in perspective, and create inner happiness. Sood developed the SMART Program, which addresses emotional resilience in the form of “interpretations.” Each day of the week, targets interpret what gratitude, compassion, acceptance, meaning, forgiveness, celebration and reflection/prayer mean to them.16
Other wellness activities may include journaling, meditation, yoga, exercise, volunteer activities, eating healthy and personal hobbies. Above all, when confronted with workplace bullying, health and well-being need to come first. Maintaining wellness is of paramount importance. Targets should ask themselves what they like to do to unwind and relax. What are they grateful for? How do they show compassion to themselves and others? The answers to these questions will help keep nurses grounded by providing a sense of happiness and comfort when coping with this tragedy.
Those feeling the effects of bullying often need to start a path to wellness with basic, practical steps. The various advantages and disadvantages of antidepressants and similar drugs to combat bullying are beyond the scope of this article, but targets must have the right attitude and take a holistic approach. Rather than a “take this pill and don't worry about it” mentality, subtle yet ongoing lifestyle changes should be included in any intervention to minimize the destructive effects of bullying. For example, exercising at the appropriate duration and intensity for the target’s fitness level (and how well they are eating and sleeping) reduces and normalizes cortisol levels. This makes it easier to lose weight, relax, and deal with stress. Without some form of exercise, employees can create a vicious cycle by covering up low energy with coffee or sugar, which stress the adrenal glands. This is common due to the odd hours many nurses must work. Sleep deprivation also creates abnormal cortisol and other hormone levels that help the body deal with stress.17,18
Avoiding computer screens and other potential disruptors of circadian rhythms before bed also improves nurse wellness. Learning healthy methods to unwind and relax lessens the risks of alcohol and drug abuse as coping mechanisms. Healthy eating plays a major role, and magnesium is calming and works well as a sleep aid. Topical absorption through an Epsom salt bath or increasing magnesium intake through diet and supplements can assist in stress reduction.3,17
Stress is directly related to physical health. Emotional intelligence is key. Researchers tested women with autoimmune diseases to determine whether their symptoms and vulnerability to the disease related to emotional connectedness and control. They were asked about emotional attachment and the ability to understand and describe their own attitudes and emotions. Not surprisingly, the surveyed women tested highly for unresolved emotional issues and difficulty in understanding and controlling their feelings. The inability to recognize and fully experience their own emotions seemed to be a defensive way to avoid painful memories. Besides impeding their clinical progress, this detachment also affected their abilities to meaningfully attach with others and communicate effectively.19, 20
The explanation is that distraction and worry have consequences that may not surface until the added stress of workplace bullying occurs. Another useful practice for healthcare workers in toxic environments is mindfulness. A study group meditated (practiced mindfulness) while the control group did not.21 Mindfulness is the exact opposite of checking texts and taking care of patients while finishing this continuing education article. Rather, it is a purposeful, calming focus on the present—on current feelings rather than plans for the future or influences from the past. After 8 hours, the meditators showed a range of genetic and molecular differences, including altered levels of gene-regulating laboratory values and reduced levels of pro-inflammatory genes, which in turn correlated with faster physical recovery from a stressful situation. The genes included cortisol secretors and cyclooxygenase inhibitors, which play a pivotal role in stress and inflammation. These differences were not present in pre-study testing, so it's safe to say the changes were due to the differences in how the two groups spent their 8 hours of quiet activity.20, 21
Although knowledge can slowly transform a work culture, the immediacy of individual incidences makes application difficult. One solution is role playing, similar to practicing for a code or fire. Cognitive rehearsal teaches predetermined responses to common bullying scenarios and attenuates bullying.22 Modify reaction, and behavior changes. Techniques emphasize learned, specific responses through listening or reading instruction. When confronted with an aggressive coworker, healthcare professionals process information through elicited scripted responses previously taught.22
Preparing responses to bullying has merit beyond the common response of, “Now I know what I should have told them, but it’s a day later.” Silence by others during bullying (sometimes called second-hand bullying) may be unethical, and anti-bullying education and protocols by themselves are not always effective. Potential bullying scenarios are easily imagined because incivility often follows the hierarchy of healthcare: physicians and administrators bully clinical professionals, who bully paraprofessionals such as certified nursing assistants. Last in line are the housekeepers and similar support staff. 23, 24 Rather than a collaborative model of care, the education of nurses, physicians, and other professionals fails to teach how to communicate and cope effectively in clinical practice. This leads to several distinct kinds of bullies to be profiled via cognitive rehearsal by healthcare professionals. The elitist, the envious, the resentful, the cliquish who bullies through exclusion, the backstabber who seeks friendship before betraying staff members, and the rumor mill who spreads negativity while taking offense whenever possible.22, 23
Combining emotional intelligence with cognitive rehearsal is especially vital when targets are bullied by supervisors. Rather than authentic or collaborative leaders who practice what they preach, bullying leaders use personal information as ammunition and try to make sure their subordinates are not building a case against them. Healthcare professionals must focus on self-care and resist the urge to isolate themselves, especially from potential allies. Excusing themselves from bullying situations or even distracting the bully with a physical object (such as an envelope or file, not a heavy paperweight) are also methods to transform from target to “workplace warrior.”7, 23
Dana, a female respiratory therapist, began her first week at a new hospital. On the second day, she was confronted by Adam, a Dana, a female respiratory therapist began her first week at a new hospital. On the second, day she was confronted by Adam, a male colleague, who asked, “Are you sure you are still single?” “Huh?” responded Dana, taken by surprise by the question. Adam placed an arm around her shoulder and replied, “I saw you on Facebook snuggled up close with a good looking man.”Feeling uncomfortable knowing he had searched her social media account, and not knowing what to say, Dana told Adam it was none of his business.
What indicators are present?
Recognizing, identifying, documenting and reporting Adam’s inappropriate questioning on their initial encounter was important to nip this behavior in the bud and hopefully prevent Dana from continuing to be a target for further bullying/abuse by Adam.
If Dana did not tell Adam to mind his own business and did not identify, document and report the initial bullying, the abuse would have remained unreported and probably would continue to occur,creating an uncomfortable workplace for her.
Bullying is pervasive in healthcare, but it must be identified before it can be addressed. Promoting a welcoming culture with clear communication skills and consequences for bullying behavior is an excellent place to start. As healthcare professionals take ownership of both their health and workplace culture, they become a powerful force for decreasing bullying and supporting targets. The result is happier and healthier staff, decreased costs, and improved patient safety and experience.