1. Miller, Lisa A. CNM, JD
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Ask any nurse from any specialty whether he or she is familiar with the phrase "nurses eat their young," and you will likely get not just an uncomfortable laugh but a firsthand account of an experience of bullying in the workplace. An example from the author's personal experience is illuminating:


Working at a community hospital as a nurse-midwife, the author overheard a conversation between 2 staff nurses at the desk. The 2 nurses were discussing a third nurse, who was relatively new and in a room with a patient in very active labor at the time. The discussion was centered on the new nurse's time spent in the room with patients, and her perceived unwillingness to help other nurses on the unit, described as she would rather "hide in her patient's room." The punishment the 2 nurses at the desk had devised was to ignore the new nurse when she called for the routine of a second nurse to come to the patient room during a delivery and let her "fend for herself and see how she likes it."


The plan was thwarted when the author pointed out the safety ramifications and suggested that an alternate plan might include actually speaking to the new nurse, who may simply have been feeling overwhelmed with her responsibilities, may actually have perceived value and satisfaction from being with her patient in the labor room, and may not have realized that coworkers saw her as unresponsive to their needs. Sadly, this anecdote is neither unusual nor extreme.


While the typical stereotype of bullying in nursing is a male physician demeaning or insulting a female nurse, the realities regarding workplace violence (WPV) are much broader and cross gender and education lines both in clinical nursing and in academic programs. In fact, one study demonstrated that nursing faculty reported bullying by students (contrapower harassment) more often than faculty in any other academic major.1 Regardless of setting, perinatal and neonatal nurses will likely encounter episodes of WPV. In fact, they may be perpetrators. This column provides an overview of incivility in the workplace, including information on an innovative and successful approach to reduce its occurrence.



While many professionals may believe that regulatory bodies or national organizations have clear definitions for what constitutes bullying, incivility, and WPV, this is simply not the case and deserves some review. In July 2015, the American Nurses Association (ANA) published a position statement on bullying in the workplace and included the terms "incivility," "bullying," and "workplace violence," none of which were specifically defined. The position statement called for best practice strategies aimed at prevention and mitigation and stated that the nursing profession would have essentially a zero tolerance policy for violence of any type from any source.2 In 2016, The Joint Commission (TJC) identified workplace bullying as including verbal abuse, verbal and nonverbal threats, intimidation or humiliation, and interference or sabotage of work duties. TJC also categorized WPV into 5 areas (threats to professional or personal status, isolation, overwork, and destabilization) but notes that bullying does not include illegal harassment or illegal discrimination.3 In addition to the work of TJC on the subject, scholarly research and an attempt at consensus regarding definitions for WPV specific to healthcare settings were the focus of a 2-part study by Boyle and Wallis.4 The 2-part approach included a literature review, followed by a consensus-building workshop at an international conference on violence in the health sector. Definitions were proposed for 6 distinct types of WPV: bullying, verbal abuse, threat, physical abuse, sexual harassment, and sexual abuse.4 WPV can also be described in terms of its direction, with lateral or horizontal violence most commonly described as occurring between colleagues on the same level of power within a hierarchy and vertical violence as occurring between different levels of power, typically originating with the higher-level person being the perpetrator of WPV. But even a cursory review of the literature on WPV reveals a variety of interpretations and characterizations for WPV terms. What becomes clear is that definitions for WPV are not universally recognized and certainly are not easily defined by any entity. Institutions will need to create clear and concise definitions for WPV before addressing prevention and mitigation.


While institutions may need to individually reach consensus on appropriate classifications and definitions for WPV, the evidence regarding the impact of WPV on nursing is well known. Problems with morale, productivity, and absenteeism are well documented.3 In an ANA survey of more than 3700 nurses and student nurses, nearly half reported experiencing verbal abuse or nonverbal aggression from a colleague.5 These issues, in turn, lead to increased nurse turnover, a costly situation in terms of both patient safety and bottom line budgetary costs. The dollar cost of replacing 1 nurse may be as high as $100 000 in some specialties.6 The hidden costs of WPV include other organizational costs, such as loss of talented and skilled nurses who are driven to seek other employment opportunities or even leave the profession; the impact on patient relations and hospital and organizational reputation when patients and families witness WPV; and societal costs as healthcare entities struggle with staffing and safety issues that arise from incidents of WPV.



It may be surprising to nurses that there is no current federal or state law that specifically addresses bullying in the workplace. In some situations, antidiscrimination laws may apply to WPV. Federal antidiscrimination laws prohibit discrimination based on factors such as race, sex, religion, age, or disability; many state laws go further and provide additional prohibitions on discrimination in the workplace; but whether state or federal, the claim of illegal harassment or an illegal hostile work environment will require legal counsel and evidentiary standards that may be difficult to meet in order to advance a claim. There are also time limits for reporting these types of claims; nurses may have as little as 180 days to report a claim to the Equal Employment Opportunity Commission. If WPV includes threats of physical violence or acts of unpermitted touching, these can give rise to criminal assault charges against the individual perpetrator, and this may extend to the employer in some situations. Defamation claims may be an option where a nurse's reputation is harmed by verbal bullying. But in all of these situations, there are significant legal hurdles to be cleared in order to be successful. Nurses may have difficulty with the social and emotional costs of litigation in this area, as demonstrated by the experience of nurses involved in other whistle-blowing situations.7


With the general legal recognition that employers have a responsibility to provide a safe work environment, some states have legislatively mandated WPV prevention programs for healthcare employers, and a majority of states have laws that designate specific penalties for the assault of nurses. Both employers and nurses must become familiar with state laws that relate in any fashion to WPV. Realistically, outside of federal and state antidiscrimination laws and criminal or personal injury litigation, nurses need internal processes and the support of hospital administration as well as nursing and medical leadership to effectively bring WPV to an end. A new approach that uses the observations of coworkers may provide an effective solution.



While professional organizations promulgate mandates for respectful and safe work environments and discuss the importance of zero tolerance for incivility, the fact remains that bullying and WPV must be addressed in some concrete manner if it is to be reduced and removed from the healthcare culture. Webb and colleagues8 at the Vanderbilt University Medical Center (VUMC) have published a radically novel and dramatically effective approach to decreasing disrespectful and unsafe behaviors by physicians and advanced practice professionals; it could serve as a template for a similar approach to address these same concerns in nursing. The core premise of the program is the concept that coworkers are all aware of disruptive, disrespectful, and unsafe behaviors and these observations, when documented and appropriately discussed and presented, could be used to change behavior and promote safe and respectful practice. VUMC developed the Co-Worker Observation Reporting System (CORS) as a structured approach to addressing behaviors that undermine safety and team effectiveness. Webb and colleagues8 describe in detail an approach that includes specific prelaunch and preparedness actions; an intervention process that begins with an online submission by a coworker of unsafe or disrespectful behavior; and timely peer-to-peer discussions of the report. For situations where there are multiple reports or patterns of behavior emerge, there are additional interventions. During a 39-month period, 3% of physicians were associated with 42% of the coworker reports. The majority of physicians who were provided with intervention had no further reports the following year.8


While the CORS method as published reflects an approach that was used to address behavior of physician and advanced practice professionals, the concept is one that could work for nursing professionals at all levels. Creating a reporting system for coworkers and a peer-to-peer intervention approach could drastically alter the landscape of WPV in nursing. But until such time as the CORS work can be duplicated in nursing environments, there are other ways that employing the power of coworkers can be effective. Suggestions for dealing with disrespectful or bullying behaviors are listed in Box 1.


Box 1. Strategies for nurses and their coworkers to decrease WPV [Context Link]


1. Disrupt the violence-when you witness a colleague being bullied or disrespected, say something to stop the situation; even simply standing between the nurse and the perpetrator can often end the bullying behavior.


2. Provide emotional support to a colleague following an attack or disrespectful interchange.


3. Become aware of your own behavior, assess your communication skills, and reflect on your own use of language, are you an unknowing perpetrator?


4. Engage nursing management in discussions and education regarding WPV; do not hesitate to report episodes of WPV.


5. Engage your colleagues in fostering supportive and nurturing behaviors toward new and inexperienced nurses; these nurses are the future and deserve to be mentored and encouraged.


6. Learn how to disagree respectfully.


7. Don't gossip or rush to judgment without facts.


8. Seek help and emotional support if you are a victim of WPV, do not remain silent.


Abbreviation: WPV, workplace violence.



WPV is a pervasive and dangerous problem in healthcare, and it is seriously destructive to the specialty of nursing. There exist a wide range of behaviors that constitute WPV, and national and organizational standardization of definitions for WPV is needed. Bullying, incivility, and other types of WPV are occurring at an alarming rate and are tied to increased social, emotional, and economic costs nationally and worldwide. Federal and state legal options are currently limited, although they do exist. Innovative programs of intervention have been developed to address provider-level instances of WPV; similar programs for nursing need to be explored and developed. While the reasons for WPV are many and varied, there are proven responses that can diminish bullying and disrespectful behavior and coordinated efforts by coworkers and colleagues can be effective. Nurses can move other nurses toward respectful dialogue and healthy work environments simply by acting as role models. As Maya Angelou said: ...people will forget what you said, people will forget what you did, but people will never forget how you made them feel." It is time for nurses to reject the cliche that we eat our young. Empowerment and support, transparency, and zero tolerance for WPV, these are the solutions.


-Lisa A. Miller, CNM, JD




Perinatal Risk Management and Education Services


Portland, Oregon




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