1. Flateau-Lux, Laura R. BSN, RN
  2. Gravel, Tammy MSN, RN

Article Content

Bullying among nurses has been discussed in the nursing literature for nearly two decades.1 The concept has been identified with many terms, such as horizontal violence, lateral violence, and relational aggression.2-4 All of these can be best described as forms of psychological and social harassment perpetrated by one nurse against another through overt and covert behaviors.3,4 Examples of covert behaviors include nonverbal cues, deliberately withholding information, gossiping, and sharing private informa-tion that wasn't intended for others to know. Overt behaviors are more blatant and include sabotaging another nurse, scapegoating, taking actions that prevent another nurse from doing his or her job (such as hiding items needed for patient care), forming cliques, and exhibiting passive-aggressive behavior toward a particular nurse.3

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This article discusses the effects of bullying on nursing students and new graduate nurses entering the workforce and explores strategies for changing a culture of bullying on nursing units.


Early Exposure to Bullying

In the clinical setting today, nursing students are exposed to bullying behavior early in their nursing education. Stevenson, Randle, and Grayling conducted a survey that measured the frequency and types of bullying behavior among 313 second-and third-year nursing students in the United Kingdom during their last clinical placement. About 53% of nursing students in this study indicated that they'd experienced some form of bullying during their clinical placement from physicians and senior members of the nursing staff within specialty areas such as adult medicine, pediatrics, and mental health. The most common behaviors indicated were being ignored/excluded (34%), experiencing destructive criticism (30%), resentment (29%), and being humiliated in the presence of others (29%).5


Simons set out to explore bullying experienced by newly licensed RNs in Massachusetts and its effect on intention to leave the workplace. The target population for this study was nurses who were newly registered and less experienced, because the researcher discovered from a literature review that this population was the most vulnerable to bullying.6 Out of 511 survey re-spondents, 78% were grouped into the novice category (defined as nurses who'd had their license for 36 months or less).7 Thirty-one percent of respondents indicated that they'd been bullied based on these criteria: On a weekly or daily basis over the last 6 months, the RNs experienced at least two negative behaviors perpetrated by another nurse.6


The researcher additionally sought to measure the intention to leave the place of employment among those bullied. Simons found that bullying had more influence on intent to leave than any other factor, including marital status, race, and earned income. While the results of this study support the concept of bullying among nurses within the clinical setting, the researcher couldn't conclude that bullying occurs more often among newly licensed nurses within their first 3 years of practice compared with experienced nurses who are newly licensed in Massachusetts by reciprocity from the sample provided by the Massachusetts Board of Registration in Nursing.6


At the end of this survey was an open-ended section for participants to provide any comments on the concept of bullying. Out of the original 511 respondents, 184 nurses completed the comment section. In 2010, Simons expanded on the original study using a qualitative design to share the respondents' experiences, as this further demonstrated the concept of bullying in the workplace. Four themes were identified in the stories provided by the respondents: structural bullying (perceived punitive and undue actions taken by supervisors), nurses eating their young, feeling out of the clique, and leaving the job. Some of the most notable comments on these four themes involved being given a workload that wasn't manageable, feeling like senior nurses took joy in keeping information to themselves at the expense of the new nurse, feeling alienated, and intentions of leaving their job and/or the profession as a result.8


Bullying in the First Year of Practice

Most of the research on bullying among nurses with up to 1 year of experience has been conducted in the United Kingdom and New Zealand. McKenna et al.2 conducted a classic study exploring bullying against newly licensed RNs during their first year of practice in New Zealand. The goals of the study were to identify the types and prevalence of bullying behaviors toward nurses within their first year of practice, explore the impact of these behaviors psychologically, understand the consequences of this behavior, and determine to what extent these new nurse graduates received training to manage bullying.


Out of the 1,169 questionnaires mailed, 551 respondents completed questionnaires for a response rate of 47%. Results indicated that:


* over 50% reported feeling that they were being treated like a student


* 46% reported being given a lot of responsibility without supervision


* 34% reported being denied access to learning opportunities


* 34% felt emotionally neglected


* 20% indicated that they were told by another nurse that they'd endure repercussions for speaking out against bullying behavior.2



Several respondents reported psychological consequences that included frustration, fear, depression, anxiety, and mistrust. A few reported physical consequences, such as headaches, weight loss, and fatigue.


Forty-one percent of respondents indicated that they'd had some form of undergraduate training to help identify and manage interpersonal conflict among staff. Only 13% indicated that they'd had some form of training to manage interpersonal conflict since becoming an RN.2


Repercussions During the First Year of Practice

A review of the literature establishes that nurses in the clinical setting experience bullying, both in the United States and abroad. International studies have further supported the concept that bullying is most prevalent against new nurse graduates during their first year of practice. When a new graduate enters the workforce, his or her first real position creates an impression of the nurse's role in healthcare.9


A nurse's first year of practice is a time for acquiring new skills and knowledge and building confidence. New nurses are typically enthusiastic about caring for patients and want to make a difference in the world. They enter the profession with the assumption that they're needed, yet some are greeted with behaviors from seasoned nurses that can be psychologically distressing. The resulting interpersonal conflict, job conflict, and stress leave the new nurse with a less positive impression about the role of a nurse. This issue can create such a distraction that it compromises patient care.10 Research suggests that bullying behavior must be exposed in order to stop it and to implement programs that allow new nurse graduates to grow and develop confidence within their profession.2


Nurse Retention and Patient Safety Issues

As the bullying phenomenon continues and impedes the professional growth and development of newly licensed nurses, it may directly impact staff retention. According to Griffin, after 6 months of employment, 60% of new RNs in the United States quit their job due to some form of bullying.3


Besides undermining the morale of new nurse graduates, bullying also compromises patient safety. Nurses who are bullied are less likely to seek help and ask questions, potentially leading to errors and substandard patient care.11,12


To ensure patient safety and embrace an environment conducive to learning and patient centered outcomes, any bullying must be addressed and eradicated by establishing and enforcing zero-tolerance policies. Addressing and eliminating this culture of horizontal violence will raise the profession of nursing by enhancing productivity and enthusiasm, reducing risks to patient safety, supporting recruitment and retention, and strengthening nursing as an ethical profession.


Role of Professional Organizations

When interacting with peers, nurses are held to the standard of professional behavior by federal, state, and local regulatory agencies and nursing organizations. A nurse declares his or her commitment to the profession by following the rules and guidelines set forth by the American Nurses Association (ANA) and state Board of Nursing. For example, nurses have an ethical obligation to act in accordance with provision 1.5 of the ANA's Code of Ethics for Nurses with Interpretive Statements. In a section on relationships with colleagues and others, it states: "The nurse maintains compassionate and caring relationships with colleagues and others with a commitment to the fair treatment of individuals, to integrity-preserving compromise, and to resolving conflict."13


Can this be said for the culture of nursing today? Fostering a culture that condemns bullying against nurses is an obligation for nursing leaders.


In January 2009, The Joint Commission issued a set of leadership standards for all accredited organizations that require healthcare institutions to:


* establish a code of conduct that addresses adverse behaviors in the workplace


* promote a nonpunitive forum that allows the reporting of such behavior


* create a disciplinary process for those who bully.14



Literature suggests that nursing leaders should evaluate unit culture and become aware of the signs of bullying in order to take swift action in enforcing the cultural expectations that support a code of professional conduct. Nurse leaders should encourage seasoned staff on the unit to reflect on their first year of practice to enhance their mindfulness of the challenges and fears that new nursing graduates undertake when entering the clinical setting for the first time.15


Measuring the Culture of a Workplace Environment

Several evidence-based studies suggest using mentoring programs and establishing interdisciplinary groups to survey staff about work behaviors to help enforce a zero-tolerance policy.16,17 Some tools and interventions that have been implemented on nursing units to measure bullying are the Negative Acts Questionnaire-Revised (NAQ-R) and a cognitive-behavioral technique.3,18


The NAQ-R is a 22-item questionnaire that describes different types of bullying behaviors and measures perceived exposure to bullying in the workplace. The NAQ-R was used in the Massachusetts study discussed earlier with good internal reliability measured by the Cronbach alpha.6,18


A helpful cognitive-behavioral technique is a strategy called cognitive rehearsal. Griffin conducted a study with 26 newly licensed RNs to measure the effectiveness of cognitive rehearsal strategies in confronting a bully in the workplace. This technique taught the new RN to respond differently to the behavior by rehearsing prototypical responses to the most frequent forms of bul-lying, such as withholding information, raising of the eyebrow, sabotaging, and backstabbing. By learning and practicing appropriate responses to bullying behaviors, the nurse is empowered to confront the bully. This strategy was proven effective in the study and also raised awareness of inappropriate behavior in the workplace.3


Academic Implications

Awareness of the issue of bullying against new nurse graduates serves as a call to action among educational institutions to take a primary prevention approach. By raising awareness and shining a spotlight on the stressors and oppressive encounters that new nurse graduates will experience in the real world, educators can prepare them to respond appropriately and help eliminate these cruel customs.19


Education is the means by which nursing students learn about the cultural and social aspects of nursing.20 Educators could play an active role in exposing nursing students to the phenomenon of bullying and teach behavioral techniques and skills that can be applied to nursing practice.10 Every educational institution with a nursing program has a responsibility as a whole to implement interventions at the course level to combat bullying and positively influence job retention.


The following are recommendations that educational institutions could include within the nursing curriculum to empower nursing students to manage bullies and become advocates for change3,19,20:


* Provide insight and prepare students for incidences of poor professional interactions with the necessary skills to manage these situations via simulation.


* Teach cognitive behavioral interventions that promote skill development of positive behavior when confronted with bullying by using discussions, role playing, and feedback.


* Enforce the importance of reporting bullying behaviors that are witnessed by or perpetrated against the nurse.


* Educate students about the psychological consequences of bullying behavior, such as fear, frustration, anxiety, stress, and dis-concerting feelings of wanting to leave the nursing profession.


* Teach coping skills necessary to combat these stressors.



Changing Cultural Norms

The existence of a culture that accepts bullying must be recognized and challenged before strategies to eliminate this offensive behavior can be implemented. Research suggests that this acknowledgement begins with individual nurses within the culture of the nursing unit.21 For strategies nurse leaders can use to eliminate bullying in the workplace, see Initiating Cultural Changes Within the Organization.


In 2001, the American Association of Critical Care Nurses set forth six essential standards that they believed were required of acute and critical care nurses to promote a healthy working environment: skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership.22


Nurses have a personal obligation to contribute to their working environment and meet this standard. Poor working relationships can be improved if all nurses make an effort to care about their peers and take ownership of their role in workplace violence. Nurses need to begin to support each other and confront the behavior. Nurses ought to come together to make it known that this behavior is not acceptable and will not be tolerated.23


Addressing the issue of horizontal violence at all levels, from entry level professional nursing education to organizational and departmental culture, will improve professional nurse satisfaction, patient outcomes, and organizational outcomes, and support the retention of nurses as direct care providers.


Initiating Cultural Changes Within the Organization15

Nurse leaders have a direct responsibility to set a standard of zero tolerance for horizontal violence. Strategies for meeting this goal include:


* developing a unit/department-based code of conduct drafted in collaboration with staff with expected behaviors targeting the elimination of horizontal violence


* empowering staff to report/address peers who perpetrate horizontal violence without fear of retaliation


* discussing any bullying incident at staff meetings, highlighting the behavior as horizontal violence


* providing staff with conflict management skills and effective strategies eliminating horizontal violence


* reinforcing and enforcing processes put in place to address and eliminate incidences of horizontal violence.





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