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“Don’t solve the problem until you know what the problem is and whether it even exists,” shaffer says. “Identify who might be involved and who may be exposed.”
A common perception is that a lot of the bullying and disrespect that can create a toxic work culture in health care settings is directed by physicians toward nurses. Surprisingly, nurses appear to observe a hierarchy within their own ranks that may be just as mean-spirited, says Elaine Larson, PhD, RN, FAAN, CIC, associate dean for research at the Columbia School of Nursing in New York.
“A doctoral student who just graduated did her dissertation on bullying among nurses,” Larson says. “Actually, there is quite a body of literature on bullying within the profession of nursing, and it is rather common. What she found was that a majority of nurses at some time in their career have been harassed or bullied by a colleague in nursing. So I don’t think it is specifically just physicians to nurses.”
Factors contributing to such behavior include a high-stress work environment where lives could literally be at stake. Any bullying or disturbing disrespect on top of the normal job stress can endanger the health of both patients and workers.
“The tradition in medical education has been much more confrontational,” Larson says. “There is such a high level of stress and rushing around that a sense of respect and mutual kindness [is lost].”
As a result, some health care cultures “eat their young,” to borrow a disturbing phrase from the aforementioned dissertation. “Some of the rude and aggressive behaviors probably have to do with self-protection,” Larson adds. “There are some people who have learned to move along the blame as much as possible and cover their backs.”
In another study, a 2014 survey of more than 2,000 nursing school graduates found that 48% were concerned about being the victims of bullying or working in a hostile environment, according to Kaplan Test Prep of New York City.1
“It’s a pretty common phenomenon that nurses talk about,” says Susan Sanders, DNP, RN, NEA-BC, vice president for Kaplan Nursing.
The organization conducted its survey to see if the problem was pervasive, Sanders says.
“Sure enough, the majority of new nurses had heard about bullying, knew someone who experienced it, or experienced it themselves,” she adds.
They primarily described peer-to-peer bullying, Sanders says.
“It’s thought to be the result of having high-pressure jobs,” she notes. “In general, nurses are very collaborative and yet they have high expectations, so if you come into our environment and are not meeting our expectations for whatever reason, it falls on us to do more.”
Resentment of new and inexperienced or otherwise slower nurses can set in and result in bullying behavior, she adds. Kaplan Test Prep’s survey found that 79% of nursing school graduates think nursing schools should provide special training on how to handle workplace bullying or hostile work environments.
ANA developing position paper
The issue of workplace violence and bullying has become a major topic of discussion among health care leaders. For instance, the American Nurses Association (ANA) of Silver Spring, MD, has convened a professional issues panel on workplace violence, bullying, and civility.
“Our focus is to develop a position statement for RNs and employers, and it includes background research,” says Jaime Murphy Dawson, MPH, senior policy analyst in the department for nursing practice and work environment at ANA.
ANA’s panel of 25 health care professionals now is working on the draft document. ANA also formed an advisory panel of more than 400 registered nurses.
“The exciting part is when we develop these policy foundational statements, we’ll do continuing education programs and toolkits,” Dawson says. “This is the first step in a multipronged initiative to address workplace bullying and violence.”
ANA recently surveyed nurses, asking about bullying and violence, as part of the preparation for the panel. Four thousand nurses responded to the unpublished survey, and a majority said they were interested in the topic of violence and bullying because they wanted to create a safer health care workplace, Dawson says.
Nurses reported the groups most likely to commit a violent act were patients and their family members, and the groups most likely to exhibit incivility were their colleagues, including nurses and physicians, she says.
“For a long time, bullying and violence were accepted as part of the job,” Dawson notes. “We hope that culture is changing and nurses will be comfortable reporting incidents.”
Employee health leaders can help reduce bullying and incivility by encouraging employees to report incidents and also by teaching them the difference between acceptable and unacceptable behaviors, she suggests.
“Then you have to show nurses that what they’re reporting is leading to policy changes,” she adds.
Akin to hazing
Research into hospital workplace bullying suggests there is a hazing culture among nurses, says James Blando, PhD, an assistant professor at Old Dominion University College of Health Sciences in Norfolk, VA.
“It’s an ‘I had to deal with it, so you have to deal with it,’ attitude,” he says. “Bullying goes beyond name-calling.”
While interviewing nurses for research into hospital violence, Blando found that some forms of bullying had major impacts on their home life. For instance, some nurses reported that one way a hospital manager might get back at an employee is by cutting their work hours when they count on the extra income or by giving them less desirable tasks.
“That’s a real significant issue because health care is the type of work where you have to work together,” Blando says.
Another commonly reported problem was bullying by physicians, he says.
“Since physicians are the money-generators, nurses would say they felt management was extremely permissive toward them,” Blando says.
In one example, there was an emergency department nurse who made a decision about putting a patient on a fast track. A doctor disagreed angrily, throwing a clipboard at her and breaking her nose, Blando recalls.
“He was reprimanded, and that was it,” he says. “We heard of another surgeon who was operating on a patient and then threw a bloody scalpel at a nurse who was not moving fast enough. The patient had AIDS, and the physician’s hospital visiting privileges were revoked, but he went on to another hospital.”
The key to preventing these incidents and other less extreme forms of bullying is to teach nurses and other hospital staff that putting up with bad behavior is not part of their jobs, Blando says.
“You should have respectful behavior among all of your coworkers,” he says.
Bullying in hospitals is not a new phenomenon, says Susan King, MS, RN, executive director of Oregon Nurses Association (ONA) in Tualatin, OR. ONA has addressed the issue with resources about bullying available online (http://www.oregonrn.org/?103).
The bigger issue is the hostile work environment that many nurses and other health care employees experience, King says.
“Nurses, whether in a hospital or long-term care facility, are finding that individuals who are making decisions are not clinicians and have little understanding of what patient care requires,” King says. “Yet they are making decisions on staffing, and front-line managers are responsible for implementing and upholding bad decision-making.”
Hospital employee health leaders could identify bullying as an important worker health issue and take preliminary steps to determine if there is a problem in their hospital, Sanders suggests.
They can do this with a staff survey that asks:
The goal is to identify patterns and trends. For instance, if there is a high nursing turnover rate, then stress and factors like bullying could play a role, Sanders notes.
Employee health has an opportunity to identify what’s going on and determine ways to support new nurses and other staff to prevent resignations due to a hostile work environment, she adds.
“There is literature that says one-third of nurses leave their nursing jobs within the first year,” Sanders says. “It may be due to bullying or to not recognizing what the nursing career is about, but that’s a huge financial impact on the hospital.”