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Break the bullying cycle

To the public, the nursing profession exemplifies caring and compassion. Yet bullying may exist in all areas where nursing is practiced. From “eating our young” to sabotaging and scapegoating nurse colleagues, bullying is a serious problem that jeopardizes unit morale and patient safety.

What’s in a name?

“My preceptor rolled her eyes and looked at me like I was stupid every time I asked her a question. I finally stopped asking. Doesn’t she realize I’ve only been a nurse for 3 weeks?”

The young playground bully who resorted to physical means to show superiority has grown up. Now he or she uses psychological or social behaviors to cause harm in more subtle ways in the workplace.

Bullying is defined as “repeated, offensive, abusive, intimidating, or insulting behaviors; abuse of power; or unfair sanctions that make recipients feel humiliated, vulnerable, or threatened, thus creating stress and undermining their self-confidence.” Depending on the situation, bullying may be termed horizontal hostility, lateral violence, hazing, relational aggression, or workplace incivility. When the bully is on the same authority level as the victim (as when a nurse bullies another nurse or a manager bullies another manager), the behavior may be termed horizontal hostility or lateral violence. Of course, bullying also may take the form of aggressive behavior by superiors toward subordinates.

Common bullying behaviors used by nurses include innuendo, verbal affront, undermining, withholding information, sabotage, infighting, scapegoating, backstabbing, failing to respect privacy, and breaking confidences. Such behaviors as gossiping, exclusion, eye-rolling, silence, and humiliation also may qualify as bullying. Whatever we call it, the concepts and behaviors are similar.

Origins of a bully culture

Although bullying exists in all professions, the problem seems especially prevalent in nursing. In a survey of more than 4,000 critical-care nurses, 18% reported they’d experienced verbal abuse by another nurse. About 25% rated the quality of collaboration among registered nurses (RNs) as fair or poor, and 22% rated respect for other RNs as fair or poor.

Approximately 65% of respondents in a survey at a large medical center said they frequently observed horizontal bullying behaviors among coworkers. What’s more, up to 70% of nurses who were bullying victims left their jobs; in contrast, one-third of those with health problems left their jobs because of those problems. Roughly 60% of new RNs quit their first job within 6 months of being bullied, and one in three new graduate nurses considers quitting nursing altogether because of abusive or humiliating encounters.

A vicious cycle

Sociological literature shows that oppressed group members tend to act out against one another because they lack control over their situation. They can’t verbalize frustrations or concerns to higher-ups for fear of punishment. Inability to express feelings and concerns diminishes their self-esteem. Powerlessness further lowers their self-esteem and triggers the cycle of oppressed group behavior undertaken to boost self-esteem—which in turn causes more frustration, lack of coworker support, and conflict.

In many healthcare facilities, administrative hierarchies promote and perpetuate oppressive conditions, such as inability to take uninterrupted breaks or meals, inadequate staffing ratios, limited supplies, and little recognition of nurses’ ability to think critically. These conditions contribute to the problem.
Bullying behaviors differ by gender. Males more often express aggression physically or by working their way into positions of power. Females tend to use more cerebral means, such as defamation, humiliation, and betrayal of trust.

Survivor syndrome

Nurses who survive bullying early in their careers tend to carry their learned behaviors with them. They accept the bully culture as part of the job and eventually choose one of two paths: leave the unhealthy work environment in search of a healthier one, or participate in the culture either as a bully or bystander.

Effects of workplace bullying

Bullying creates a toxic work environment with serious consequences for victims, institutions and, ultimately, patients. Victims feel isolated from other team members. They may dread going to work. Their self-esteem decreases and their self-doubt suppresses their initiative and innovation. Eventually, they become impaired psychologically and occupationally. Many new nurses lack confidence to begin with and require positive feedback about their performance; bullying makes them feel invisible, incompetent, and inferior. (See Generational clashes by clicking the PDF icon above.)

Bullying victims may suffer stress-related health problems, such as nausea, headache, insomnia, anxiety, depression, weight changes, and alcohol and drug abuse. Research on bullied nurses in the United Kingdom indicates workplace bullying accounts for a third to one-half of stress-related absenteeism. In Canada, one in seven adult suicides results from workplace bullying.

Bullying affects bystanders as well, making them wonder if they’ll be the bully’s next victim; this stress can lead to depression and anger. What’s more, if they decide to report the abuse, they may fear retaliation and a “whistleblower” reputation—fears that shield the bully from discipline.

Financial burden of bullying

Bullying erodes job satisfaction and morale, in turn increasing absenteeism, lowering productivity, and promoting high staff turnover. Given the high cost of hiring and orienting new nurses, losing nurses within the first year creates a tremendous financial burden on institutions.

“Our new manager didn’t like me from the start. Within a month, she was assigning me more and more extra tasks until I couldn’t get them all done. When I tried to talk to her about my workload, she said I should be able to handle it because I was the one with the master’s degree. Later she fired me, stating I didn’t meet our department’s expectations, even though I had several complimentary letters from patients and other managers.”

Low work satisfaction also decreases patient satisfaction, which can affect reimbursement and patients’ likelihood to recommend the facility.

A threat to patient safety

Bullying reduces patient safety by interfering with teamwork, communication, and collaboration. When a nurse manager withholds information, purposely assigns too heavy a patient load, or doesn’t provide assistance when needed, patient safety in that unit may decrease and potentially fatal errors may occur. (See Is your manager a bully? by clicking on the PDF icon above)

Nurses who’ve been bullied feel isolated from coworkers; they’re reluctant to ask questions and afraid to speak up to advocate for patients. High nurse turnover jeopardizes continuity on the unit, and may leave nurses without adequate experience or knowledge to recognize and act quick­ly on potential patient problems.

Creating a healthy work environment

As in most dysfunctional situations, the first step toward change is admitting a problem exists. If bullying has long been accepted as the norm, the problem may be hard to recognize. Education is crucial; understanding the reasons for bullying and associated behaviors can help nurses realize they’re capable of stopping the oppression. Nurse leaders can benefit from learning how to identify and curb bullying behaviors. Also, learning effective communication strategies helps nurses respond to bullying in a positive manner.

Individual efforts can make a big difference in promoting the culture change.

  • Remember what it was like to be a new nurse. Treat new nurses as you would have wanted to
    be treated as a “newbie.”
  • Make an effort to welcome new nurses and help them feel they’re part of the group.
  • If you’re being bullied, address the behavior immediately. Bullying might be so ingrained in the workplace culture that bullies may not be aware of their behavior.
  • Use conflict-management strategies when confronting a bully.
  • Identify the problem clearly when it occurs, and raise the issue at staff meetings.
  • Serve as a role model for professional behaviors.

Nurse managers and chief nursing officers have an important role in breaking the bullying cycle and maintaining the new culture. They should encourage staff to report bullying incidents, ensure that those who experience and report abusive incidents will be safe from retribution, and take action to discipline bullies, counsel victims, and implement corrective measures to prevent recurrence. Bullying can be addressed by unit-based councils, with council members serving as role models for other staff members.

Zero-tolerance policy

To end abusive behaviors, hospitals must implement clear zero-tolerance policies. The message must be communicated loudly and clearly from upper administration that the bullying culture must exist no more.
In 2004, the American Association of Critical-Care Nurses issued a public policy statement that serves as a clear mandate for facilities to adopt a policy to end abusive and disrespectful behavior. In 2008, the Center for American Nurses released a position statement on lateral violence and bullying in the workplace that calls for promoting a culture of safety that encourages open, respectful communication. Also, the Joint Commission has issued leadership standards that include creating processes for managing bullying behaviors and adopting a code of conduct for staff.

Bullying and other abusive and disruptive behaviors in nursing must end. The destructive effects reach out in all directions to create unhealthy, unsatisfying work environments. Treating all members of the healthcare team with respect leads to collaboration, open communication, and teamwork and promotes delivery of the high-quality care we all strive for. We can break the cycle of bullying and abuse through individual accountability, a mentoring culture, and support for our nursing peers.

Selected references

Center for American Nurses. Position Statement: Lateral violence and bullying in the workplace. 2008. http://www.nursingworld.org/Bullying-Workplace-Violence. Accessed November 14, 2011.

Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. 2008 July 9;40:1-3.

Vessey JA, Demarco RF, Gaffney DA, Budin WC. Bullying of staff registered nurses in the workplace: a preliminary study for developing personal and organizational strategies for the transformation of hostile to healthy workplace environments. J Prof Nurs. 2009 Sep-Oct;25(5):299-306.

Terri Townsend is a critical-care nurse and faculty member at Indiana University Health Ball Memorial Hospital and Ball State University School of Nursing in Muncie, Indiana.

43 thoughts on “Break the bullying cycle”

  1. Rachel says:

    I just started working for a 65 bed hospital. It’s very small, in a small town, with very small minded people. It was the only offer I received after graduating from school in December. Everyone here is very close and I am basically the odd man out. I am being bullied, I can’t walk down a hall without someone whispering or stop talking in mid-sentence when I walk up. I don’t think I’ve given them any reason to think that I deserve this kind of behavior. I haven’t even completed my training and I

  2. Anonymous says:

    I experienced bullying by the manager day in a hospital setting & reporting it to human resource made the matter worst because they decided not to address the bullying. Had HR addressed the matter the end result may not have led to me resigning. Human Resource must step up & get involve in the matter instead of ignoring it. It was not worth the risk of neglecting the patients due to lack of help & support nor was it worth the risk of losing my license. The entire unit mimiced the manager.

  3. RN says:

    I haven’t experienced much bullying from co-workers, but have too often had to deal with condescending, power-tripping supervisors who’ve forgotten that they’re NOT indispensible.
    A pat on the back or a bit of understanding goes a long way in the work environment.

  4. The Author says:

    Thank you all for the great comments. Bullying is an issue that shows no favoritism to position, whether it be a staff nurse, manager, or student. It will continue to be a “hot topic” until all employers adopt and enforce zero-tolerance policies in the workplace.

  5. Greg says:

    Actually, the step that for me made the most difference was going entirely Per Diem: no security or benefits, but I have far more practical power, and am treated far better than ever before

  6. Greg says:

    To address this issue, hospitals would mostly need to show some substantive interest – policy means nothing without enforcement, actually produces a fiction of action that can retard real progress

  7. Greg says:

    Bullying is unusually gratuitous and mean in Nursing, without much less violence than that in other settings (like my high school). It has led me to occasional job changes – I can handle myself, but the toxicity and negativity tends to rub off over time, and I’d rather spend more energy more usefully. Managers have nearly always done their very best to entirely pretend the issue doesn’t exist – at times they have seemed a floor’s single most most intimidated staffer

  8. Anonymous says:

    Terri, this is an excellent article. And although I have an opinion on an answer to the issue; only a zero tolerance would suffice, given the right people were in charge to implement. If you understand what I’m saying……

  9. Anonymous says:

    To 1:06 am -I totally agree. To 10:21pm – I ran a business for 20 years before going into nursing. As part of my leadership position, I became a part of my team of 40+ employees, most of which were older than myself,I had no trouble. Policies/rules are only a part of leadership. If a policy is obviosly not in the best interest of the nurse or the patient, then it is the responsibility of management to own up and do right. Jesus asked, “Do we help someone on Sunday, or not, because of a rule?”

  10. Anonymous says:

    I have seen the ugly effects that bullying has on patients and nurses. While most bullying is done by coworker to coworker, I believe the manager sets the stage to tolerate or have a zero tolerances for bullying. What I have observed, most of the bullying is initiated by management and administration toward certain individuals. Once a stigma is place on a nurse, it sets him/her up for bullying. It is a disgrace to the healthcare profession for this to happen. I would like to help prevent it.

  11. caudill32 says:

    This is truly an issue in nursing and is the reason why after 5 years I feel so dissatisfied with my job. I have been guilty myself of being part of the gossiping and offered a cold shoulder or two myself. I do not want to ever be that way and am trying to retrain myself, but I see how it is so easy to become a part of this dirty side of nursing and the frustrations that lead to it, such as inequality and favoritisms, fear that a coworker dumps on you or is incompetent and so on…

  12. Anonymous says:

    With all due respect to our colleague who posted at 10:21 pm, I must conclude that she is a manager. The dirty little secret in nursing and healthcare is that in senior administration there is absolutely no regulatory body or oversight. Therefore, the administrators have free reign to lead their organizations however they wish.

  13. Anonymous says:

    While bullying certainly does go on, in my experience it is far more often done staff nurse-to-staff nurse. Sometimes line staff believe their manager is “bullying” when in fact that manager is enforcing policies and regulations that line staff have been ignoring. Often, managers are perceived to be “nice” when in fact they are tolerating mediocre behavior, and “bullying”or “mean” when they insist on adherence to professional standards.

  14. Anonymous says:

    Excellent topic. It is a shame that the Magnet Program permits bully nurse managers and nurse COOs to fool them when they apply for their Magnet Accreditation. Does the Magnet Program not realize how many of their “Magnet” hospital so called nurse leaders have bullied their staff, but on the one day that Magnet visits, all is just an act. Then, when the Magnet visitors leaves, many nurses lose their jobs and the intimidation continues. Magnet needs an Ethics Officer to monior their program.

  15. Anonymous says:

    Thank you for the great article! I have been a victim of serious horizontal violence in a hospital environment. I hoped to see changes after reporting it, but no efforts have been to education our nurses. I have researched the subject in-depth and believe we need an awareness, a loud vocal zero-tolerance policy!

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