Over the past several months, bullying has made national headlines. Once thought of as occurring only on the middle school playground, it has entered professional sports locker rooms, causing the suspension of professional athletes, cyberspace, contributing to the deaths of schoolchildren, and the workplace, causing disruption, threatening patient safety, and utilizing precious resources. Although bullying is widely recognized, a culture of silence perpetuates. Fear of repercussion contributes to underreporting and thus inadequate and ineffective interventions. This column focuses on the effects of bullying in the workplace, specifically the health care environment, and interventions to overcome its presence and perpetuation.
Bullying, lateral violence, and harassment are all terms that describe inappropriate collegial behavior. Lateral violence describes ridiculing and demeaning a colleague. It may present itself by the use of criticism, undermining, finger pointing, and bickering (Roy, 2007). Bullying is characterized by repetitive, offensive, abusive, intimidating, or insulting behavior. Abuse of power exemplifies the actions of the bully, resulting in unfair sanctions and the deliberate intent to cause psychological or physical harm. Harassment differs in that it exploits a "difference," that is, gender, race, ethnicity, age, or disability. Bullying is related to horizontal violence and harassment, with the distinction being the presence of a real or perceived power threat between the instigator and the recipient. The acts also are repetitive and occur over time (Vessey, 2012). For the purposes of this column, they will not be differentiated. Both encompass inappropriate professional behavior and must be eradicated from the workplace (Beauchesne, 2006).
A bully demonstrates manipulative and controlling behavior. He or she seeks to control their environment by controlling the people in it. The reasons behind the behavior are varied: job dissatisfaction, lack of control, lack of autonomy, increased workload, and decreased resources. The older, experienced nurse is a frequent bully. New nurses are common targets and are especially vulnerable to being bullied, as they do not possess the skills or knowledge to stand up for themselves and are not confident in their clinical skills. They are often intimidated by the older, experienced nurse. They are often given the hardest assignments and often humiliated in front of others if they ask for help. Older nurses treat the newer nurses "like I was treated." Most nurses are familiar with the term "nurses eat their own." The cycle is renewed with each new orientation class that enters the unit. This phenomenon is not unique to the nursing profession, and a bully is not solely the older nurse. In the health care environment, any person who is perceived to be at the lower end of a hierarchy, such as a medical student, resident, nurse, aide, and ancillary help, is at risk for being bullied. Unit organizational culture such as the presence of "cliques" and informal leaders also sustain the cycle. The unit leadership inadvertently tolerates and rewards the negative behavior, by looking the other way, or by the promotion of the bullies into positions of authority, even though they may not have the best leadership skills. Bullies are described as being "able to get things done," which perpetuates the cycle (Gaffney, Demarco, Hofmeyer, & Budin, 2012).
In order for bullying to be addressed, it must be recognized and reported. Characteristics of bullying are harsh communication, passive aggressive behavior such as eye rolling, infighting, backstabbing (complaining about a coworker behind his or her back and not speaking to them directly) and scapegoating (blaming another). Additional characteristics include giving a coworker the silent treatment, withholding information from a colleague to make their work more difficult, sabotage, broken confidences, and failure to respect privacy (Stokowski, 2010).
Bullying has a downward spiral effect on both the intended target (the victim) and the unintended targets, our patients and coworkers. The victim continually tries to avert the attacker to avoid provocation, causing unremitting stress. The constant stress causes both physical and psychological trauma to the victim and also negatively affects the workplace. The victim may experience anxiety, irritability, panic attacks, tearfulness, depression, mood swings, loss of confidence, diminished self-esteem, decreased ability to concentrate, and increased use of tobacco and alcohol. Physical symptoms include disturbed sleep, headaches, increased blood pressure, change in eating patterns, gastrointestinal upsets, and loss of libido. In addition, communication among staff members is impaired, there is decreased collaboration, and the person affected may have impaired decision making, all of which impair patient care and jeopardize patient safety. The institution suffers from poor staff performance, absenteeism, and professional disengagement. This, in turn, causes further decreased teamwork, lower staff morale, and lower patient satisfaction scores, ultimately resulting in an increased financial strain on the institution, as a result of both actual employee health costs and lost potential patient revenue (Vessey, Demarco, Gaffney, & Budin, 2009).
Education, awareness, and prevention are key to changing the culture. It must move from one of benign neglect to zero tolerance. The Joint Commission issued a sentinel event alert in 2009, in which it outlined a new leadership standard to address disruptive and inappropriate behavior. It delineates that a hospital have a code of conduct that defines acceptable, disruptive, and inappropriate behavior. It also mandates the implementation of a process for managing this type of behavior (The Joint Commission 2008).
Strategies must be designed for both the nurses and the organization to affect the change. Nurses need to support one another both during and after an episode (Stokowski, 2010). This can be done by simply interrupting a conversation or by standing alongside a colleague if a bullying altercation is in progress. Reporting is essential. The victim or the witness or both need to be encouraged to report the incident. Organizational strategies to support reporting include the stance of Zero Tolerance and anonymous reporting. Staff members need assurances that there will be no repercussions if a claim is made. Education can be achieved through mandatory inservices. Antibullying campaigns such as benice, B.E.N.I.C.E (Bullying, Elimination, Nursing, In a, Caring, Environment), can be adapted by hospitals to reflect uniqueness of its culture (http://www.themhf.org/education/be_nice). Unit-specific behavior guidelines and expectations can aid in the education. The operating room may incorporate behavior standards for the surgical team, where as a hospital unit may focus instead on individual interactions.
The message from society is loud and clear. Bullying will not be tolerated. Policy and procedures must be developed to eradicate the presence of bullying and thus change the culture of the hospital. Everyone deserves the right to work in a bully-free environment.
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