Authors

  1. Dellasega, Cheryl A. PhD, CRNP

Overview

Relational aggression is a type of bullying typified by various forms of psychological (rather than physical) abuse. It includes such behaviors as gossiping, withholding information, and ostracism. Although relational aggression in girls has garnered considerable interest, scant research on this subject has been conducted among adult women or among nurses in particular. Most studies of bullying among nurses have been conducted outside the United States. This article reports on the relevant literature on bullying among health care workers, describes common scenarios, and offers a framework for changing workplace environments affected by bullying.

 

Article Content

Bullying among children-especially what's known as relational aggression, the often subtle forms of psychological and social bullying that girls tend to engage in-has received the attention of both researchers and the entertainment media (the film Mean Girls, for example). But comparatively little attention has been paid to such behavior in adults. That's about to change, at least for health care professionals. As of January 1, the Joint Commission is requiring institutions to have a process in place for addressing "intimidating and disruptive" behavior in the workplace.1 (To listen to a podcast on this topic featuring Jane H. Barnsteiner, PhD, RN, FAAN, a member of the Joint Commission Sentinel Event Advisory Committee, go to http://www.ajnonline.com and click on "Podcasts.")

 

Little investigation has been done on nurse-nurse bullying in the United States; most of the relevant research available in English comes from European countries, including the United Kingdom, and Australia. And few studies have distinguished nurse-nurse bullying from bullying of nurses by other health care professionals. But here's a sampling of what's known:

 

* A British survey of more than 1,000 clinical and administrative health care workers found that 44% of nurses and 35% of other staff reported experiencing "peer bullying" in the workplace within the previous year, although bullies weren't identified by job title.2

 

* A Finnish study of more than 5,000 hospital employees found that 5% reported being bullied at work; of these, 50% were nurses, by far the largest group.3

 

* A 2006 survey of more than 4,000 critical care RNs in this country found that 18% had experienced verbal abuse from another RN; more than 25% of all respondents rated the quality of their communication and collaboration with other RNs as fair or poor.4

 

* One small descriptive study among new graduate nurses at a Boston hospital found that nearly half had had "lateral violence" directed at them.5

 

* A survey of more than 500 new graduates in New Zealand found that "covert interpersonal conflict" was common.6

 

 

Stories of aggression among nurses abound on the Internet. For example, at http://allnurses.com, the forum thread "What makes a bully nurse?" generated more than 70 responses. Descriptors included "overly critical," "bossy, pushy, and [a]rrogant," "feels [horizontal ellipsis] she can put down a fellow workmate in front of others," "catty, cliquish," "loves to correct you," and "[uses] 'hit and run' comments." And in a poll at http://www.aboutmytalk.com, 23 of 27 respondents (85%) "fully" agreed with the statement "Nurses thrive on backstabbing each other."

 

Why, in a profession founded on caring and collaboration, is bullying a problem?

 

WHAT IS AND WHAT CAUSES RELATIONAL AGGRESSION?

Definitions. Although there's no standard definition of bullying, most experts agree it involves repeated efforts to cause another person physical or emotional harm or injury. It can reflect an actual or perceived imbalance of power or conflict, but it can also occur between peers and even friends. Relational aggression, a type of bullying, refers to the use of psychological and social behaviors rather than physical violence to cause harm.7 It's sometimes characterized as indirect or covert bullying, but that can be misleading; for example, calling a coworker "incompetent" to her face is a form of relational aggression, but it isn't covert. Some use the term lateral or horizontal violence to describe aggression between nurses in the workplace,8-10 but these terms seem too limiting; they refer to aggression between people at the same hierarchical level, whereas relational aggression can also occur between people at different levels, as when senior nurses bully new graduates. Relational aggression can extend beyond working hours and the time of employment and can occur in person or in cyberspace.

 

It's generally accepted that boys and men express aggression more often through physical violence and that girls and women express it through character defamation, humiliation, betrayal of trust, and exclusion,11 all of which are characteristic of relational aggression. The reasons for this difference aren't well understood. Because only about 6% of the 3 million RNs in the United States are men,12, 13 I surmise that relational aggression is the predominant form of bullying among nurses. [Editor's note: Because relational aggression occurs mainly among women and most nurses are female, this article uses female pronouns. But men can also be victims or perpetrators of relational aggression. One large Norwegian survey of assistant nurses found that male respondents were more than twice as likely to report exposure to bullying at work than were female respondents.14]

 

Causes. It's unclear why girls and women favor relational over physical aggression. One theory is that females may be biologically hardwired to respond to stress differently than males. After analyzing both animal and human studies, Taylor and colleagues theorized that whereas both sexes can exhibit the fight-or-flight stress response, which is believed to be activated largely by testosterone, females are more inclined to use "tend-and-befriend," a response based on caregiving and attachment behaviors triggered by oxytocin and other female hormones.15 They also argue that because female aggression ("fight") is mediated less by testosterone, it tends to be more social and "cerebral" than physical in its expression.

 

Some researchers have focused on the developmental origins of relational aggression. According to a review by Archer and Cote, girls tend to use more indirect and relational forms of bullying than boys and to display this preference quite young (one large study found evidence of this predilection in girls as young as two years of age).16 And Crick and colleagues concluded that, despite some mixed findings, the research overall has demonstrated that relational aggression is more likely to occur among girls, particularly in early and middle childhood.17 Many experts believe this preference persists into adulthood. Indeed, for my book Mean Girls Grown Up: Adult Women Who Are Still Queen Bees, Middle Bees, and Afraid-to-Bees, I listened to hundreds of women's stories about the adolescent-like bullying they'd experienced as adults.18

 

In Woman's Inhumanity to Woman, psychologist Phyllis Chesler posited that internalized sexism is a factor: "The fact that someone is a woman does not mean that she likes, trusts, or works well with other women [horizontal ellipsis] [A]s men do, women either idealize or demonize women."19 Others have considered organizational factors. Noting that "nursing work is increasingly driven by managerial imperatives," Australian researchers Hutchinson and colleagues argued that the resulting "intense scrutiny" of nursing activities compounds nurses' stress and fosters an atmosphere conducive to bullying.20

 

The deleterious effects of relational aggression are numerous and lasting. Among children they include excessive anger, anxiety, depression, loneliness, delinquency, and even death (by suicide or homicide).21-23 And for adults, relational aggression can affect quality of life both on and off the job. In a study of 1,180 public-sector employees, 71% reported experiencing relational aggression in the workplace; its negative effects included lower job satisfaction and greater psychological distress.24

 

Although the dynamics of relational aggression have yet to be fully elaborated, it's my belief that such aggression often occurs within, rather than between, groups-as is the case with nurse-nurse bullying. And it's not clear that those affected want help in addressing the problem. Judith Briles, an author and expert on workplace issues within health care environments, has stated that her offer to help one nursing organization deal with nurse-nurse bullying was pointedly rejected25; I have had similar experiences.

 

WHAT NURSES' STORIES REVEAL

As an author and expert on relational aggression among girls and women, I've served as a public speaker, radio and television show guest, and consultant. Audience members have often urged me to explore relational aggression among nurses in particular. I began to offer workshops for nurses in which I spoke about relational aggression and invited participants to describe their professional experiences with this type of bullying. I didn't take on this work as a formal study, and I didn't keep track of how many stories I heard. But the strong impression they made on me is confirmed whenever I talk with staff nurses and nursing administrators. The following is based on what I've been told (in person and in letters and e-mails) during five years of listening to nurses' stories.

 

Triggers. Certain situations and events predispose one to being bullied. These include being a new graduate or new hire; receiving a promotion or an honor that others feel is undeserved; having difficulty working well with others; receiving special attention from physicians; and experiencing severe understaffing.

 

Patterns. Certain behavior patterns that can be found in every setting and nursing specialty emerge repeatedly in nurses' stories. All of these patterns have made other nurses who were present feel intimidated or frustrated-even when they weren't targeted. (Doubtless, the aggressors were also feeling distress. For more, see No Bullies Here, at left.) The following types of nurse bullies are based on the descriptions nurses commonly give when sharing their stories.

 

The Supernurse. In any given situation, this nurse has not only "been there, done that," but was better at it than you and will make sure you know it. She may be more experienced, educated, or specialized. Some nurses described an elitist attitude prominent among such nurses, who might convey their sense of superiority through comments and body language such as a head toss or an exasperated sigh. In some cases the Supernurse believes her corrective comments are helpful; in others she may be compensating for her insecurity. Supernurses often don't realize how offensive their behavior is to others.

 

The Resentful Nurse develops and holds grudges. The perceived transgression may have occurred years ago, but she isn't about to let go of her bitterness and anger toward the transgressor. She will pit herself against that nurse, often encouraging others to join her in "ganging up" so the entire unit gets caught up in the drama. The hostility, whether expressed by one person or a group, permeates the work environment, and nurses targeted in this way have been known to quit their jobs.

 

The "PGR" Nurse. Some nurses use put-downs, gossip, and rumors (PGR) to bully other nurses. In a stressful situation, instead of working collaboratively, this nurse is likely to turn on others. Even in relaxed circumstances, when she's present casual talk can quickly turn hurtful. Her targets can seem random and may change daily or more often. She's quick to take offense at a neutral remark and respond with a put-down or an innuendo. It's possible that in some cases the PGR Nurse's original intent is to bond rather than to bully-one study investigating gossip among college students found that sharing negative attitudes about a third person promoted greater closeness between the first two than sharing positive attitudes26-but the damage is done all the same.

 

The Backstabbing Nurse cultivates friendships and gains confidences that she then betrays. She uses information as a weapon, and her efforts often seem intended to enhance her power. This "two-faced" behavior creates mistrust and prevents nurses from working together effectively; people tend to censor what they say and do when they're afraid their words and actions will be used against them.

 

The Green-with-Envy Nurse covets what she doesn't have, whether it's in terms of appearance, possessions, status, or personality. This nurse finds something or someone to envy and expresses her bitterness through comments and uncooperative or other behaviors. The nurse she envies often isn't even aware that she's a target.

 

The Cliquish Nurse uses exclusion as a means of aggression. Cliques form when two or more nurses band together and, for various reasons, exclude other nurses from their group. It's normal for people who work together to form friendships, but it's harmful when some consider themselves the "in" group and judge others to be "out." Cliquish nurses might show favoritism in which nurses they help, ignore one nurse if she joins them at meals, or practice selective gift giving or flattery.

 

For representative stories, go to http://links.lww.com/A638.

 

A PLAN FOR CHANGE

Several experts see changing a negative work environment as the responsibility of administrators. Hutchinson and colleagues advocate decentralizing authority and creating "more democratic and less hierarchical workplaces."27 Edwards and O'Connell point to Britain's 1999 "Zero Tolerance" directive, aimed at "preventing violence and bullying incidents" against and among National Health Service staff, as a model for adoption by nurse educators.28 They also recommend that students receive "formal preparation to deal and cope with bullying"; I believe nurses being oriented on a new unit could benefit from similar training.

 

For the nurse manager.Step one. Begin by taking an anonymous survey of nurses on your unit about their perceptions of the emotional climate. (For a sample questionnaire, see Figure 1, at left.) If the responses indicate that relational aggression is a problem, develop an intervention that involves the entire unit. For example, a campaign to raise awareness might include the following points:

  
Figure 1 - Click to enlarge in new windowFigure 1. Nurse-Nurse Bullying Survey

* Relational aggression uses words and behaviors (rather than physical violence) to hurt someone.

 

* The aggressor (bully) often is insecure and angry.

 

* The target (victim) often lives in fear of what might come next.

 

* Those who witness relational aggression (bystanders) are often affected, as well.

 

 

The last point is important: relational aggression can quickly create an environment in which anxiety and mistrust flourish. One nurse recently recalled her discomfort at overhearing coworkers gossiping about another nurse. She wondered if they would talk about her next, and she felt ashamed that she hadn't defended the nurse they were discussing.

 

Distributing a handout describing specific behaviors that constitute bullying can be helpful. (For a list of some common behaviors used in nurse-nurse bullying, see Figure 2, at left. For a free flyer to post on your unit, contact me.)

  
Figure 2 - Click to enlarge in new windowFigure 2. Common Behaviors Used in Nurse-Nurse Bullying

Step two. Once nurses are speaking a common language about relational aggression, it can be useful to encourage dialogue and brainstorm solutions. Patterson and colleagues describe a process for handling "crucial conversations"-those in which the stakes are high, opinions vary, and emotions are strong.29 They observe that a safe environment in which "others perceive that we are working toward a common outcome" promotes meaningful dialogue. Their suggestions for effective conversations incorporate the concepts of assertiveness and personal responsibility: stating the facts, "owning" one's feelings, being open, and asking for feedback.

 

Another approach, known as the World Cafe, fosters "conversations that matter" using seven guiding principles.30 The process involves bringing diverse groups together in a welcoming environment, posing questions that elicit meaningful discussion, encouraging everyone to contribute, listening for patterns and insights, and allowing collective knowledge to suggest actions. The technique has been used successfully with community organizations, schools, businesses, and government agencies worldwide. To learn more, visit http://www.theworldcafe.com.

 

Step three. Create guidelines that address the specific needs on your unit. In 2004 the Institute for Safe Medication Practices, responding to an "apparent culture of disrespect among healthcare providers," outlined steps any organization can take to change that culture.31 It includes establishing a committee to study the issue further; developing a code of conduct and requiring all staff to sign it annually; establishing a "standard, assertive communication process"; and creating a conflict resolution process.

 

Ramos has observed that although the American Nurses Association offers information on conflict resolution and the nursing literature recognizes nurse-nurse bullying as a problem, "most organizational leaders haven't addressed the problem."32 She believes that nurse managers can define a unit's culture and must clearly articulate guidelines for acceptable behavior. Under her proposed zero-tolerance policy, bullying and other "maladaptive social behavior" would have consequences. But those involved would first work together to resolve the problem; they wouldn't go to the manager unless this attempt failed. Ramos also emphasizes the importance of thoroughly investigating and documenting each incident at every level, and notes that any such policy must have organizational support to succeed.

 

For every nurse. If you witness a conflict, it's important to intervene quickly to prevent minor conflicts from escalating. In many cases, a misperception or a false assumption triggers behavior that spins out of control. Bystanders often outnumber both bullies and victims and, acting individually or together, they can frequently change a situation's dynamic. For instance, you can discourage gossip by refusing to participate or walking away; you can intervene on behalf of a coworker who's being bullied by asking her to help you with a task in another location, speaking up on her behalf, or simply standing beside her.

 

It's also helpful to find alternative ways to relieve stress. When a colleague's having a difficult time, a friendly word of encouragement or an offer to back her up can be invaluable. Creating a strong sense of community in the workplace, through recognition that each person is important, valued, and necessary to the team, can make relational aggression less likely. Focusing on what unites the group rather than on what divides it will foster collaboration.

 

Further questions for investigation might include: "How many nurses leave a job because of relational aggression?" "How accurate are these categories for describing nurses' behavior?" and "What causes relational aggression in the nursing profession?"

 

Bullying in the ICU

When asked to recall if I'd ever been bullied by another nurse or witnessed bullying among nurses, several instances quickly came to mind. At the time they occurred, however, I'd seen them less as instances of bullying than as rites of passage.

 

Although bullying among nurses can occur in any setting, in my experience it's particularly evident in ICUs. Maybe that's because to be effective in that fast-paced environment, you have to be blunt about what you need from coworkers. There often isn't time to worry about feelings or manners. In an emergency, especially, it's easy to make an insensitive remark or lash out at someone. If that becomes a habit, you may find you've become a bully.

 

As a specialty, I think ICU nursing tends to attract more competitive, and thus more aggressive, nurses than other specialties do. When I started working in an ICU, if you were new you had to prove yourself, whether you were a recent graduate or an experienced nurse. New nurses were assigned two or three mentors. If you were lucky, you got mentors who loved to teach and weren't threatened by sharing what they knew; you could enjoy learning and gain confidence in your skills. But if a mentor was burned-out or felt threatened, she or he could make life miserable. Often you just couldn't win. If you asked too many questions, you were labeled dumb or clueless; if you didn't ask enough questions or seemed too confident, you were a know-it-all. And you also had to prove yourself to the more seasoned staff nurses on your shift and the next one. They frequently gossiped about which nurse on the previous shift it was bad to follow. If your shift report was lengthy, the receiving nurse might look away or start a conversation with someone else, as if she was bored. If your report was concise, she might accuse you of being unhelpful by not providing enough information.

 

One experience I had as a new ICU nurse has stayed with me. My shift was nearly over; I had almost finished tidying up my patient's room and was about to give report to the senior nurse when I heard her mutter, "Oh, great, by the time I clean up the mess, I'll be at least an hour behind." I was hurt; I prided myself on leaving my patients clean and with their IV bags at least half full. I was confident about my care of this patient, so I decided to confront the senior nurse. "I'm sorry, but I was unaware that I'd ever left you a mess," I said. "If I have, I apologize. And in the future, I'd appreciate it if you'd bring a problem to my attention so I can correct it."

  
Figure. Kendra E. Du... - Click to enlarge in new windowFigure. Kendra E. Durdock

She looked surprised, as if she hadn't expected me to approach her. Then she said, "Well, you've never left me a mess, but I've heard from other nurses that you've left them messes in the past." I asked her to encourage them to tell me if there was ever a problem with my work and promised to address it. In short, I stood up for myself, and I conveyed that I was open to feedback. From then on, our relationship changed. Her hostility toward me vanished and she began to trust me, even asking me to watch her patients when she went on break.

 

Kendra E. Durdock

 

Kendra E. Durdock, BSN, RN, is a diabetes treatment plan coordinator at Pennsylvania State University Milton S. Hershey Medical Center in Hershey.

 

No Bullies Here

During a recent workshop, one woman-I'll call her Corinne-rolled her eyes, folded her arms across her chest, and said, "Nobody on my unit is a bully." I noticed her coworkers exchanging furtive glances. Later one of them whispered to me, "We have a terrible problem with bullying."

 

I believe most nurses are compassionate people; indeed, it's part of the job. That said, I've talked to, heard about, and worked with some who hid their humanity well. Many, like Corinne, don't seem to realize how much their negative attitude or behavior affects those around them.

 

How would your coworkers describe you? Think about your behavior during the last few workdays. For example, were there times when others seemed angered or hurt by something you said or did? Did your coworkers avoid you? Did you feel compelled to comment solely on what your colleagues did wrong, rather than on what they got right? Did you gossip? If you find yourself answering yes to any of these questions, it's possible that, at least some of the time, your behavior is relationally aggressive.

 

If you're not sure whether you use relational aggression, try monitoring your behavior at work for a shift or two. You may unconsciously be communicating in an aggressive manner.

 

REFERENCES

 

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To listen to a podcast related to the articles, go to http://www.ajnonline.com and click on "Podcasts."