Most nurses enjoy taking care of others — it’s what drew them into their profession and provides satisfaction throughout their careers, to varying degrees. Caregiving at its best has mutual benefits for nurse and patient. It’s a job that requires hard work, discipline, and the emotional resilience to help patients, especially those in severe pain or in the process of dying.

Nursing has always been a stressful career, but between today’s demanding productivity goals, the changeover to electronic records and patients who want to diagnose and treat themselves by Google, nurses face unprecedented levels of job stress. In such situations, self-sacrifice is often taken to unhealthy extremes.

Physicians under stress have a tendency to act out in disruptive behaviors. Nurses under stress are more apt to either suffer in silence — or engage in stealthy, passive-aggressive forms of disruptive behaviors that, while harder to detect than physician outbursts, can be equally damaging.

Horizontal hostility at work

Horizontal hostility and “nurses eating their young” are two terms commonly used to describe a pantheon of mean, bullying behaviors inflicted by nurses on nurses, including:

• Inconsistent supervision, unfair or punitive actions by nurse managers who are perceived to be “playing favorites.”
• Cliquishness among colleagues, for instance, one or two nurses left out of team lunches, outings or conversations
• Withholding of needed information and other attempts to sabotage work
• Backbiting, scapegoating, or publicly criticizing co-workers

In their 2010 qualitative study of newly licensed registered nurses, Simons and Mawn found substantial evidence that “workplace bullying has profound negative effects on the health and well-being of individuals.”

Codependency and burnout

It’s ironic that the nurses who bully and the nurses who don’t confront their tormenters share a common personality trait – codependency or a pattern of compulsive caregiving behaviors. They frequently have no identity other than as a caregiver.

• The nurse doing the bullying is often a codependent perfectionist with an insatiable need for approval and willingness to undermine or sabotage any newcomer that might threaten his or her status.
• The nurse being bullied is often a codependent people pleaser, who dislikes confrontation and won’t ask for the same kind of help he or she so generously gives to others.

In either case, codependent nurses are at high risk for compassion fatigue and burnout.
According to the American Nursing Association, there are roughly 2.6 million nurses practicing in the United States today — in 1989 Snow and Willard claimed that as many as 80% of practicing nurses exhibit signs of codependency.

That statistic is particularly concerning in light of 1992 research by Davidhizar & Eshleman, which suggests that the codependent behaviors of one individual may damage the morale and motivation of the entire healthcare team.

Causes of codependent behavior

Given two nurses working the same shifts in the same department, why does one nurse exhibit signs of burnout or codependent behavior while the other takes the same level of job stress in stride? There could be a variety of reasons.

Many nurses come to the field with codependent behaviors formed in childhood. While this subject has not been heavily researched, a 1994 study by Holder, Farnsworth, and Wells found that 70% of the randomly selected nursing students surveyed came from families with histories of sexual molestation, chemical dependence or physical violence. A 2004 study of 35 southeastern and southwestern nursing programs conducted by Parker, Faulk and LoBello also found relationships between family pathology and codependency traits.

On the other hand, people from the most “normal” of homes will start to exhibit abnormal behaviors when subjected to prolonged periods of stress. For many nurses, the solution is to find another job or leave the field. Nurses who can’t find other work and aren’t in a financial position to simply quit, are caught between a rock and a hard place — and often end up becoming part of the problem themselves.

Nurse empowerment: An idea whose time has come

Happily, healthcare organizations across the country are beginning to recognize the high cost of over-stressed nurses—not just in recruiting and training their replacements but also in terms of patient safety.

The Joint Commission’s Sentinel Alert #40, “Behaviors that undermine a culture of safety,” took effect in 2009. The alert addresses disruptive behavior among all providers, and the negative impact it can have on teamwork, communication, a collaborative work environment and, ultimately, patient safety, and quality of care. Since then, most organizations have put in place systems for reporting abusive behavior.

Nurses are more empowered than at any point in history to speak out when they witness a potential mistake or unacceptable behavior. Yet, many nurses remain convinced that a doctor or supervisor “will have them fired” if they complain. Nurses often feel guilty about whatever consequences doctors or co-workers face for their behavior.

Ultimately, it doesn’t matter how much structure a healthcare organization puts in place to facilitate communication and address workplace issues; nurses who remain locked in perceptions of themselves as people who can carry the world on their shoulders will continue to burn themselves out.

Nurse wellness: A global approach

The most important thing nurses can do for themselves, their patients and the people they love is to make self-care their priority. Parents traveling with children are always cautioned to put on their own oxygen masks first — because if they pass out while putting masks on their children, nobody survives. The same idea applies to nurses.

Nurses who practice effective self-care provide better care, have longer careers and are more satisfied with their work and their personal lives. Self-care, of course, involves all the things nurses tell their patients to do – exercise, eat well, sleep well and be an advocate yourself. Like their patients, most nurses fail to follow through on many of their resolutions – particularly when the life and death demands of their jobs interfere.

Organizations are increasingly realizing that supporting nurse wellness is important in terms of preserving patient safety and satisfaction, as numerous studies have shown. Retention is also an issue, as a 2011 AMN Healthcare survey showed that 16% of surveyed nurses want to switch to a less demanding role in nursing, 5% each wish to switch to part-time work or to a non-nursing job, and 6% wish to retire.

Supporting nurses: Taking meaningful steps

The first level of support is more cultural in nature. It starts with ensuring that nurses feel comfortable reporting instances of bullying or other disruptive or inappropriate behavior, regardless of the source—and then knowing that something will be done about it. This involves having clear policies and codes of conduct, and making sure there is high awareness of what is acceptable and what is not acceptable.

With this solid foundation in place, the organization then can begin to build on that with additional efforts such as:

• Ensuring there are clear reporting mechanisms in place, where nurses and other staff can report violations in a confidential manner without fear of retaliation. Most often, this would occur through the HR department for health systems, hospitals and larger group practices. A follow-up mechanism is also important—letting those who report know what was discovered and, if appropriate, what is being done. For smaller practices, appointing a clinic ombudsperson (who may even be an external party to ensure impartiality), may be a good solution.
• Promoting better communications among nurses and other staff. This can take the form of workshops on such topics as understanding communication styles and how to work more effectively together, addressing and dealing effectively with workplace conflict, and team management and team building skills, especially for managers. Facilitated discussions within and across work groups also can be helpful, using trained internal or external facilitators. These kinds of initiatives can empower nurses by providing avenues to have a true voice, and allow issues to come forward before they result in conflict and greater stress. Again, it’s important that, as issues are brought forth, they’re acknowledged and addressed. Otherwise, it becomes just another meaningless exercise that can breed apathy or cynicism.
• Creating mentoring programs that pair more experienced nurses with less experienced or newer nurses. This can have two-way benefits, as the more experienced nurses can guide and mentor their younger counterparts, helping them avoid work-related pitfalls and understand the workplace culture, and the newer nurses can help the more experienced nurses understand the needs and perspectives of a newer generation of nurses.
• Forming a wellness committee specific to nursing staff. Depending on the organization and the desired scope, wellness committee members can be involved in a variety of efforts such as mentoring and intervening with troubled colleagues, creating educational opportunities for nurses on anything from dealing effectively with stress to coping with grief and loss, and designing wellness programs to address both mental and physical wellness issues. As with all of these efforts, it’s important that the organization support the wellness committee with administrative, time and monetary resources to ensure a strong ongoing program that focuses on achieving measurable results. A third party facilitator (e.g., an HR Employee Relations specialist or an external team facilitator) can be helpful in creating goals, measuring results, and working with administration, where necessary, to obtain necessary resources.

Organizations also need to support individual nurses and staff. Many healthcare organizations now offer Employee Assistance Programs (EAPs) that provide a variety of wellness services at the individual and organizational level, including:

• Health and Wellness Coaching: EAP consultants can help nurses build programs for everything from exercise and weight loss to reducing blood pressure or cholesterol.
• Life Coaching and Assertiveness Training: Nurses who aren’t comfortable with confronting superiors or co-workers can work through scenarios with an EAP consultant.
• Psychological Counseling: Many issues can be resolved with a few calls or office visits provided free of charge by their EAP, but nurses who want to pursue longer courses of therapy often look to their EAP for referrals to local psychiatrists, psychologists and social workers appropriate for their needs
• Work/Life Balance Coaching: Many nurses have difficulties achieving work/life balance and this imbalance takes a toll on their health and relationships, both at and outside of work. An EAP consultant can help nurses address the symptoms and underlying issues.
• Peer Coaching: Some programs offer nurse peer coaches who can help nurses deal with both work and personal issues from the standpoint of someone who has “walked in their shoes,” providing valuable perspective and mentoring

Creating awareness of programs, encouraging participation and ensuring access are very important in making sure that all resources are valued and used. Normalizing the many issues nurses face and removing the stigma from seeking help is critical to nurses feeling comfortable taking care of themselves.

Nurses who demand a higher quality of life for themselves usually get it — and then share it with everyone they encounter. Research supports it, common sense demands it, so the only question is whether or not healthcare organizations can help them achieve it.

Rick Gessler, RN, is manager of employment/employee relations-human resources at Altru Health System in Grand Forks, North Dakota, and Liz Ferron is Manager of Clinical Services at Physician Wellness Services in Minneapolis, Minnesota.

Selected references

Simons S, Mawn B. Bullying in the workplace–a qualitative study of newly licensed registered nurses. American Association of Occupational Health Nurses, 2010;58(7):305-311.

Parker FM, Faulk D, LoBello GG. Assessing codependency and family pathology in nursing students. J Addictions Nurs. 2003;14(2):85-90.

Davidhizar R, Eshleman J. Co-dependency in the workplace. Hospital Topics, 1992;70(3):15-19.

Holder LM, Farnsworth BJ, Wells D. A preliminary survey of codependency traits and family of origin status of nursing students. Addictions Nursing, 1994;6(2):76-80.

AMN Healthcare, “2011 Survey of Registered Nurses:Job Satisfaction and Career Plans.” www.amnhealthcare.com, January 6, 2011.