June 17th, 2013

Nursezone.com: Nurse Bullying

An Ongoing Problem in the Health Care Workplace

By Jennifer Larson
June 13, 2013

When children repeatedly torment other children at school, it’s called bullying, and it’s deemed a significant problem. Research shows that children who are bullied tend to experience increased levels of stress, anxiety and depression.

Unfortunately, bullying doesn’t stop at the playground gates, and children aren’t the only ones who engage in bullying behavior.

The American Nurses Association (ANA) reports that between 18 and 31 percent of nurses have experienced bullying behavior at work. Like schoolyard bulling, workplace bullying involves a real or perceived imbalance of power and repetition of the negative behavior. The behavior can be overt, such as yelling or threatening, or it can be more insidious and passive, like refusing to cooperate or perform necessary tasks.

Whatever forms it takes, bullying is a serious, complex and ongoing problem in the health care workplace that results in demoralization and decreased job satisfaction, as well as feelings of isolation, anxiety, sadness and depression.

Bullying can also result in harm to patients. In a 2008 Sentinel Alert that addressed disruptive behaviors, The Joint Commission noted that “intimidating and disruptive behaviors can foster medical errors and (lead) to preventable adverse outcomes.”

Nurse bullying is also costly for health care employers. It often results in increased turnover when nurses who are bullied choose to quit their jobs rather than remain in a work environment that makes them miserable. A 2009 MedSurg Nursing article by John Murray noted that “bullying in the workplace can cost over $4 billion yearly.”

But despite a growing body of research and a greater awareness of the problem, nurses still experience bullying far too often.

“There’s so much work to be done yet,” said Joy Longo, PhD, DNS, assistant professor at Florida Atlantic University, whose research and publications has often focused on work environments, disruptive behavior and bullying.

More research needed to find solutions

Over the last decade or so, there has been a significant amount of research into the bullying phenomenon. Reports document the existence of two kinds of bullying:

• Vertical bullying–which involves a manager bullying nurses whom he/she supervises, and
• Horizontal bullying–when nurses bully their colleagues

But workplace bullying is not just experienced nurses “hazing” the newer nurses, noted Renee Thompson, RN, MSN, founder of RTConnections and author of “Do No Harm” Applies to Nurses Too! Younger, more tech-savvy nurses sometimes behave rudely and condescendingly to veteran nurses who are taking longer to adapt to new technology.

“There’s this kind of arrogance that the newer nurses have that they bring into the work environment, and they pick on the older nurses for being slow,” said Thompson.

But many experts say that even more specific information about bullying is needed to help create effective interventions and solutions in the workplace.

The ANA released a second edition of the guidance booklet Bullying in the Workplace: Reversing a Culture last year. Now it’s preparing to launch a new health risk assessment, which will include questions about factors that could affect the health and safety of nurses, and thus will include questions about bullying, said Jaime Dawson, MPH, senior policy analyst for the ANA’s department for health, safety and wellness.

“We want to understand the nurse’s work environment and what is affecting them on a daily basis,” said Dawson, noting that this information will guide their initiative moving forward.

Another pressing need is the need for more research that evaluates the effectiveness of various bullying interventions in the health care workplace, said Shellie Simons, PhD, RN, associate professor at the University of Massachusetts Lowell’s School of Nursing.

Currently, there’s little evidence-based research that shows the value of one intervention versus another. Without that kind of evaluation, hospitals must rely on anecdotal evidence and suggestions. This type of research may be difficult but it’s necessary, Simons said.

“You go through a lot of trouble to make an intervention and do something without really knowing if it works,” she said.

Emphasis on policy and reporting

One problem that seems to perpetuate bullying in health care is the underreporting of threatening and intimidating behavior. The Joint Commission’s Sentinel Alert cited an Institute for Safe Medication Practices survey that found that 40 percent of clinicians have “kept quiet or remained passive during patient care events rather than question a known intimidator.”

The Emergency Nurses Association’s (ENA’s) 2011 Emergency Department Violence Surveillance Study of 7,200 emergency nurses found similar results, noting that the majority of respondents who said they were victims of physical or verbal abuse never filed a complaint. (Note that the perpetrators of the workplace violence outlined in the ENA study included patients, as well as colleagues and supervisors.)

And Longo noted, “That’s where policies come in. Everybody should know what policies they have.”

Formal policies do matter; as The Joint Commission stated in the 2008 Sentinel Alert, “Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it.” And in 2009, The Joint Commission began requiring that organizations establish a code of conduct that defines and distinguishes acceptable and unacceptable behaviors to maintain their accreditation.

But it’s not enough to just put an anti-bullying policy in place. Leaders should also be working to make certain that everyone is aware of the policy and the ramifications of violating it. They must also consistently enforce their anti-bullying policies.

“What really needs to be in place to make that happen are strong partnerships with HR [human resources],” said Thompson.

The ENA’s violence surveillance study found that nurses working in environments with reporting policies were less likely to experience some of the behavior associated with bullying. The authors found that “The presence of reporting policies (especially zero-tolerance policies), was associated with a lower odds of physical violence and verbal abuse.” They also noted the importance of leadership support, noting that when hospital administration and ED management are committed to addressing the issue, nurses are less likely to experience workplace violence.

Health care employers should make sure that they are very clear about their expectations for behavior–and even give very specific examples of what’s acceptable and what’s not. Something that seems very common-sense to some may not be so obvious to others, Simons said.

“Some people may not know what exactly is acceptable behavior in the workplace,” she said.

Longo noted that organizations should also consider any factors that might be contributing to the disruptive behavior and investigate those, as well. The highly stressful nature of the job could be playing a role in creating or fostering negative behavior. Systemic factors of the health care environment, such as cost containment or productivity expectations, also put pressure on nurses and other health care personnel that may be driving disruptive behavior.

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Tags: JCAHO, lateral violence, nurses, nursing, workplace bullying

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