Bullying in healthcare settings is ubiquitous, particularly episodes involving nurses, according to research and government data. Ambulatory surgery centers (ASCs) and other organizations can reduce workplace bullying by focusing on what creates a culture that allows bullying to flourish.

  • In 2016, The Joint Commission issued a quick safety notice about bullying in healthcare, defining it as abusive conduct that might involve verbal, threatening, intimidating, or humiliating nonverbal behaviors, and work interference.
  • More than half of registered nurses and nursing students say they have been verbally abused, according to data from the Occupational Safety and Health Administration and the American Nurses Association.
  • Creating a culture of caring can help an ASC stop bullying and prevent the long-term workplace effects of poor staff morale and high turnover rates.

Research shows that bullying among nurses is commonplace, destructive both to the physical and emotional health of nurses who are bullied, and detrimental to the cultural health of workplaces.

“Bullying is pervasive in healthcare settings,” says Lynda Olender, PhD, RN, ANP, NEA-BC, distinguished lecturer and coordinator of the DNP doctoral program and the Nursing Administration Leadership Program at Hunter-Bellevue School of Nursing, City Universities of New York.

A cross-sectional study of licensed registered nurses revealed that 40% of nurses were bullied. Those who were bullied were more likely to score lower on overall health and mental health questionnaires.1

Workplace bullying is like a computer virus that penetrates an otherwise safe environment and causes great harm to employees and the organization, says Brenda Burk, MSN, RN, NEA-BC, who frequently travels across the United States to speak on this topic. “When I started researching bullying in 2012, I didn’t see anyone at conferences addressing the topic,” she says. “People didn’t talk about it. It was an accepted phenomenon.”

A few years later, the health industry started paying more attention to the problem. For example, in 2016, The Joint Commission issued a quick safety notice about bullying in healthcare. The Joint Commission defined bullying as abusive conduct that might involve verbal abuse, threatening, intimidating, or humiliating nonverbal behaviors, and work interference, including sabotage and preventing someone from completing his or her work. (Editor’s Note: Read more at: http://bit.ly/2BFm7W6.)

The safety notice suggests several tactics for battling bullying behavior, including: establishing a culture and safety system that does not tolerate bullying, supporting targets of bullies and confronting bullies, educating team members on appropriate professional behaviors, holding everyone accountable for modeling desirable behaviors, and developing policies and processes that address bullying, reduce fear of retaliation, respond to witnesses of bullying, and institute disciplinary actions.

Additionally, the Civility Tool-kit (https://bit.ly/2NqnufY), a project created by members of the Robert Wood Johnson Foundation Executive Nurse Fellows program in 2012, also offers resources to help prevent bullying in the workplace. A workplace bullying assessment lists risk factors related to organizational change and asks questions such as Has there been a technological change or a pending change? or Has there been management change or a pending change?

Addressing workplace bullying has reached the mainstream, and larger organizations might follow The Joint Commission’s recommendations. But smaller healthcare organizations sometimes lack preventive measures, despite the evidence that prevention works, Olender notes.

The more researchers learn about bullying and its effects on the healthcare workforce, the more evidence is accumulated, showing that bullying poses a danger to both individual employees and the overall organization.

For instance, in a study about a questionnaire administered to all registered nurses in one regional healthcare system, investigators found that nurses who were bullied and witnessed bullying were less likely to experience psychological safety and competence development. They also were more likely to be disengaged. Researchers recommended that nurse managers and staff nurses work together to establish safe environments to discuss bullying.2

According to the Occupational Safety and Health Administration and the American Nurses Association, more than half of registered nurses and nursing students report episodes of verbal abuse. (Editor’s Note: Read more at: http://bit.ly/2RCQE0F.) Often, bullies are other nurses, who might not even be aware of their own bullying behavior. Burk was speaking about nurse bullying at a small nursing leadership seminar when she noticed an audience member who looked visibly uncomfortable.

“She didn’t raise her hand to ask a question, so I went up to her afterward and said, ‘Did you have a question? I could see that you had something you wanted to say,’” Burk recalls. “She said to me, ‘I’m a bully, and I didn’t know it. Everything you were talking about, I do. I’m going to go back to my boss and apologize because I didn’t know that’s who I am.’ That’s why I do this ... to help people change their behavior.”

Nurse-on-nurse bullying includes eye-rolling, sarcasm, belittling people, verbal abuse, exclusion from the group, unfair assignments, people deliberately not helping each other, continual criticism, betraying confidence, and sabotage, Burk explains. Bullying can negatively affect staff health, morale, and job performance, research shows. For instance, a study of Taiwan nurses and their exposure to workplace violence, including psychological and verbal harm that affected 60% of nurses exposed to workplace violence, revealed that workplace bullying affected nurses’ health more than external workplace violence.3

Burk’s passion for educating the healthcare community about bullying is driven partly by her own experience. “I started talking about bullying because I was bullied,” Burk shares. After some positive experiences as a nurse and receiving promotions repeatedly until she was in a senior leadership position, Burk found herself at the mercy of a new boss, whose first words were, “You are not good enough to do this job.”

“For 18 months, she picked on me and picked on everything I did. I couldn’t do anything right,” Burk says. “She’d call me to her office and say that doctors were complaining about everything in the operating room. When I asked for specifics — which doctors and what they’re complaining about — she said, ‘I can’t betray their confidence because they wouldn’t confide in me again.’”

These encounters left Burk feeling awful. She wanted to improve her work performance, but she could not fix something if she did not know what was wrong. It was not until Burk finally decided to quit that she learned the truth: There was nothing she could have done to prevent the abusive behavior. “I finally handed in my resignation because I couldn’t do it anymore. [The boss] said, ‘I’m surprised it has taken you this long,’” Burk recalls. The woman had purposely bullied her to force her to leave the job.

Surgery centers and other healthcare organizations need to be alert to bullying among staff members and between management and staff. Ignoring the problem can create a toxic work environment. “Why is it so bad? It’s because you are destroying your nursing staff,” Burk explains. “There are a lot of physical ailments that occur with bullying. You have hypertension, ulcers, headaches, anxiety, depression, gastrointestinal stuff.”

Patient safety also could be at risk because nurses and other staff are not capable of working on their best behavior when they are under this type of stress. “It’s also a negative for your healthcare organization because you will have the increased costs of a staff revolving door,” Burk notes. “You will have a lack of teamwork.”

A surgery center that develops a reputation for unhappy staff due to bullying will find that fewer people are interested in jobs at the facility. The solution is prevention and zero-tolerance policies. “You have to call in people and establish healthy relationships with them so that you can talk to them when there’s a problem,” Burk says. “They need to become familiar with your code of conduct.”

For instance, a manager should educate staff about the ramifications of bullying behavior. Managers should be cognizant of their own staff interactions to ensure they do not roll their eyes or reveal other dismissive signs, Burk adds.

One evidence-based initiative to reduce workplace bullying for nurses, called the ‘BE NICE Champion’ program, taught RNs to intervene when they observed bullying, using stand-by, support, speak up, and sequester tactics. The program resulted in nurses feeling more confident to intervene and respond when they witnessed bullying in the workplace.4

Researchers at James Madison University conducted a pilot study of a program to reduce nurse-to-nurse incivility. They found that the intervention raised nurses’ awareness of the problem and resulted in incivility decreasing over time.5 Olender has helped healthcare facilities reduce bullying by creating a culture of caring.

“I find that managers hate to address bullying,” she says, noting that when managers witness bullying but ignore it, those managers are part of the problem. “Then, the person is being bullied by not just one person, but the agency itself. Typically, people who have been victimized will leave the agency.” The solution is for the organization to set up a culture of caring. A group of employees can work together on the initiative. Just starting work on such an initiative could lead to positive change, Olender offers. “When you empower the staff to make decisions and come up with initiatives to improve their environment, then there’s much less bullying.”


  1. Sauer PA, McCoy TP. Nurse bullying: Impact on nurses’ health. West J Nurs Res 2017;39:1533-1546.
  2. Arnetz JE, Sudan S, Fitzpatrick L, et al. Organizational determinants of bullying and work disengagement among hospital nurses. J Adv Nurs 2018; Nov 27. doi: 10.1111/jan.13915. [Epub ahead of print].
  3. Pien LC, Cheng Y, Cheng WJ. Internal workplace violence from colleagues is more strongly associated with poor health outcomes in nurses than violence from patients and families. J Adv Nurs 2018; Oct 30. doi: 10.1111/jan.13887. [Epub ahead of print].
  4. Keller R, Allie T, Levine R. An evaluation of the “BE NICE Champion” programme: A bullying intervention programme for registered nurses. J Nurs Manag 2019; Jan 7. doi: 10.1111/jonm.12748. [Epub ahead of print].
  5. Kile D, Eaton M, deValpine M, Gilbert R. The effectiveness of education and cognitive rehearsal in managing nurse-to-nurse incivility: A pilot study. J Nurs Manag 2018; Sep 1. doi: 10.1111/jonm.12709. [Epub ahead of print].