Bullying in healthcare workplaces can have serious consequences for nursing staff, as well as patients.
In fact, bullying contributes to staff absenteeism, decreased job satisfaction, higher stress at work and the shortage of nurses in the U.S.1
Nurses show concern and care to assigned patients, but “relationships between nurses often become strained and uncaring.”2 Many variables lead to this behavior, which are not always easy to describe or mitigate.
Bullying involves overt behaviors, often occurs publicly, and may involve an authority figure and a staff member.3 Bullying may sometimes lead to physical aggression directed towards the nurse, such as throwing items in the healthcare setting.4
Relational aggression (RA) is a more subtle, covert form of bullying that generally occurs between staff members.3 Behaviors that indicate RA include gossiping about co-workers, failing to assist a co-worker with a patient, manipulating others, use of threats, non-verbal communication such as rolling the eyes, leaving others out of activities or conversations, criticism of others, and telling others’ secrets.3
Online RA can also be an issue, and it may include forwarding emails that are intended to be private, hurtful videos, blogs with negative postings about other nurses, and embarrassing co-workers in social media outlets.3 Often nursing students, new nursing graduates, and new nurses to the unit are the targets of bullying and relational aggression.4
Although there are differences between bullying and RA, the two terms will be used interchangeably for the purposes of this article.
Relational aggression and bullying are important issues because they can lead to a negative working environment.4 Hogh, Hoel, & Carneiro (2011) found that there was a significant relationship between being bullied at work and staff turnover. High nursing turnover rates are costly for healthcare organizations due to the costs of replacing and orienting new nurses.5
Research shows as many as 60% of novice nurses leave within six months of being hired in their first nursing position as a direct result of the mistreatment they receive from other nurses.6
The direct cost of orienting a new is approximately $15,000, and the indirect cost equates to 75% to 125% of a nurse’s annual income in 2004.7
While the emotional and financial toll related to RA are crucial to consider, the decrease in quality patient care is also a grave concern.4
Vessey, DeMarco & DiFazio (2011) report that medication delays, medication administration errors and falls are increased where there is a hostile work environment.8
In addition, long-term absences due to illness are more common in nurses who reported frequent bullying.9
Unfortunately, RA can become a routine occurrence that weaves itself into the fabric of the work environment. As a result of normalizing behaviors that create a negative atmosphere, mistreatment is tolerated.8
The term “nurses eat their young” has come to signify the RA that seasoned nurses perpetrate against novice nurses, and it has come to be considered a rite of passage.6 In fact, the culture of the workplace may be so acclimated to hierarchical abuse that it may not be immediately identifiable.6
The following scenario highlights how inappropriate assignments and lack of support can contribute to staff turnover. A graduate nurse came to work in the ED.
Upon completion of orientation, she was anxious about her first day without a preceptor. However, she was encouraged by the nursing manager’s reassurances that she would receive support from senior nurses. On her first day after orientation, she was given a high-acuity four-room assignment considered to be challenging even for seasoned nurses.
At the end of the shift, the graduate nurse was in tears and said she felt betrayed by nursing management. She did not understand why they would give her the most difficult assignment on her first day. The graduate nurse eventually left the ED because her working conditions never improved due to the lack of support by nurse colleagues.
RA and bullying are seen across the board at all levels of nursing, and there are multiple factors that facilitate the pervasiveness of these disruptive behaviors.
Generational differences, the demands of higher patient acuity, the challenge of learning increasingly complex technology, and the strain caused by nursing shortages make the workplace susceptible to these issues.10
In spite of these barriers to fostering a nurturing and supporting work environment, the focus must be on finding viable solutions. Prevention is optimal, but there have to be practical channels made available to effectively modify inappropriate behaviors in order to prevent the adverse consequences that result from not intervening.8
Nurses need more education on bullying and RA, as well as policies and support mechanisms concerning this issue in the healthcare organization.11 It is important for administrators to conduct surveys to evaluate the work place climate and ascertain if bullying is an issue at the healthcare organization.12 It is important for management to recognize that an authentic leadership style may lead to decreased bullying behavior and assist in having supportive working environments.13
The Joint Commission (2008) recommends that institutions implement policies that encourage nurses to report abuses early and remove the fear of retribution.14 Healthcare organizations should have a “zero tolerance” policy on bullying. At the initial orientation and annually, nursing staff need to be informed of the “zero tolerance” policy and what to do if bullying is an issue.12
Improved assertiveness training may decrease the issue of bullying in nursing.2 In addition, pairing novice nurses with mentors promotes a healthy work environment and provides support and guidance needed to navigate conflicts.7
One role-playing technique, known as cognitive rehearsal, has been identified as an effective tool in empowering novice nurses to successfully diffuse negative situations.6 By identifying common bullying behaviors and formulating responses to each one, nurses can anticipate how they can react when confronted with these circumstances. Practicing prefabricated responses beforehand not only help the nurses be prepared, it also gives them a safe environment in which to perfect their responses.7
Organizations that do not address bullying provide an environment for this problem to proliferate.8
The individual measures taken by nurses to combat RA and bullying cannot be successful without an organizational structure in place to promote and maintain a positive workplace.
Reducing incidences of RA requires a multi-pronged approach that involves nursing staff and management working toward this goal.
- Chipps, E., & McRury, M. (2012). The development of an educational intervention to address workplace bullying: A pilot study. Journal for Nurses in Staff Development, 28(3), 94-98.
- Szutenbach, M.P. (2013). Bullying in nursing. Journal of Christian Nursing, 30 (1), 16-23.
- Dellasega, C. (2011). When Nurses Hurt Nurses. Indianapolis, IN: Sigma Theta Tau International.
- Sousa, M. (2012). Management and leadership: The elephant in the room: The truth about bullying in nursing. Journal of Radiology Nursing, 31(1), 29-31. doi:10.1016/j.jradnu.2012.01.002
- Hogh, A., Hoel, H., & Carneiro, I. G. (2011). Bullying and employee turnover among healthcare workers: A three-wave prospective study. Journal of Nursing Management, 19(6), 742-751. doi:10.1111/j.1365-2834.2011.01264.x
- Embree, J., & White, A. (2010). Concept analysis: Nurse-to-nurse lateral violence. Nursing Forum, 45(3), 166-173.
- Stagg, S., & Sheridan, D. (2010). Effectiveness of bullying and violence prevention programs: A systematic review. American Association of Occupational Health Nurses Journal, 58(10), 419-424.
- Vessey, J., DeMarco, R., & DiFazio, R. (2011). Bullying, harassment, and horizontal violence in the nursing workforce: The state of the science. Annual Review of Nursing Research, 133-157. doi: 10.1891/0739-6686.28.133
- Ortega, A., Christensen, K. B., Hogh, A., Rugulies, R., & Borg, V. (2011). One-year prospective study on the effect of workplace bullying on long-term sickness absence. Journal of Nursing Management, 19(6), 752-759. doi:10.1111/j.1365-2834.2010.01179.x
- Martin, Stanley, Dulaney & Pehrson, 2008.
- 11. Farrell, G. A., & Shafiei, T. (2012). Workplace aggression, including bullying in nursing and midwifery: A descriptive survey (the SWAB study). International Journal of Nursing Studies, 49(11), 1423-1431. doi:10.1016/j.ijnurstu.2012.06.007
- Thobaben, M. (2011). Bullying in the nursing profession. Home Health Care Management & Practice, 23(6), 477-479. doi:10.1177/1084822311413556
- 13. Laschinger, H. K. S., Wong, C. A., & Grau, A. L. (2012). The influence of authentic leadership on newly graduated nurses’ experiences of workplace bullying, burnout and retention outcomes: A cross-sectional study. International Journal of Nursing Studies, 49(10), 266-1276. doi:10.1016/j.ijnurstu.2012.05.012 Lateral violence and bullying in the workplace (2008). Alabama Nurse, 35(2), 23-24.
- The Joint Commission (2008, July 9). Sentinel event: Behaviors that undermine a culture of safety. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_40.PDF
Tracy P. George and Karenmarie M. Davis are both instructors of nursing at Francis Marion University Department of Nursing.