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Letter to the Editor

Addressing Nurse-to-Nurse Bullying to Promote Nurse Retention

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Carol F. Rocker MHS BN RN

Abstract

Nurse-to-nurse bullying in the workforce is contributing to the current nursing shortage. The literature reveals both victims and witnesses of bullying suffer silently and are often confused as to what to do when presented with bullying behavior. This confusion frequently contributes to nurses leaving their chosen profession. Canadian lawmakers are now beginning to address workplace bulling behaviors. The purpose of this paper is to raise awareness of the challenges associated with workplace bullying among nurses by defining and describing the incidence and origin of workplace bullying; reporting the nature of and consequences of workplace bullying for both victims and witnesses; presenting the Canadian legal response, strategies to support victims, and approaches preventing workplace bullying; and considering the nurse manager’s role in addressing workplace bullying.

Citation: Rocker, C., (August 29, 2008) "Addressing Nurse-to-Nurse Bullying to Promote Nurse Retention" OJIN: The Online Journal of Issues in Nursing Vol 13 No 3.

DOI: 10.3912/OJIN.Vol13No03PPT05

Key words: bullying, bullying culture, horizontal violence, peer harassment, psychological harassment, preventing workplace bullying, psychological terrorization, nurses and bullying, nurse manager and workplace bullying, nursing shortage, workplace violence

Bullying among nurses in Canada is a problem that drains nurses of both energy and productivity. The Canadian Bureau of National Affairs, Individual Employee Rights Newsletter (2000) reported that bullying is not related to race or gender; rather it is a symptom of emotional distress. Regularly persons in authority positions appear either to not recognize bullying or to reject this concern (Lewis, 2004; Pearce, 2001). Nurses frequently feel at a loss when it comes to controlling the bullying behavior of other nurses. These feelings of helplessness lead to an increase in absenteeism, stress leave, and resignations, all of which contribute to the nursing shortage and cost the healthcare system millions of dollars each year in employee benefits, retention, and recruitment costs (Bureau of National Affairs, 2000).

The nursing shortage is a major concern in Canada. The Canadian Institute for Health Information (2007) reported that Canada had 252,948 registered nurses employed in 2006; 92% of these were Canadian graduates and 8% were International graduates. The number of nurses graduating in Canada has increased 5.3% from 2000 to 2005 (Canadian Nurses Association, 2008). Still, Shields and Wilkins (2005) stated in “The National Survey Report of Work and Health of Nurses “that the Canadian nursing shortage will only increase. Much of this nursing shortage has its roots in human resource management issues, such as failure to control workplace bullying (Canadian Institute for Health Information, 2007). The purpose of this article is to raise awareness of the challenges associated with workplace bullying among nurses by defining and describing the incidence and origin of workplace bullying; reporting the nature of and consequences of workplace bullying for both victims and witnesses; presenting the Canadian legal response, strategies to support victims, and approaches preventing workplace bullying; and considering the nurse manager’s role in addressing workplace bullying.

Definitions of Workplace Bullying

Workplace bullying is difficult to define. This lack of clarity has hindered the efforts of Canadian policy makers who have tried to tackle this subject. Hence, Quebec law and the Canadian Initiatives on Workplace Violence have worked to offer definitions of bullying. Quebec was the first province in Canada to amend its Labor Standards Act by defining workplace bullying. Quebec law refers to workplace bullying as psychological harassment and defines it as: Any vexatious behavior in the form of repeated and hostile or unwanted conduct, verbal comments, actions or gestures that affect an employee's dignity or psychological or physical integrity and that result in a harmful work environment for the employee (Canada Safety Council, 2005). Similarly, the report “Bullying and Intimation” as presented in Canadian Initiatives on Workplace Violence (2007) has stated that workplace bullying “constitutes offensive behavior through vindictive, cruel, malicious or humiliating attempts to undermine an individual or group of employees. These persistently negative attacks are typically unpredictable, irrational and unfair… they happen with great regularity within the workplace” (para.1).

Incidence and Origins of Workplace Bullying

Canadian nurses are not alone when it comes to workplace bullying. Cooper and Swanson (2002) have reported that workplace bullying among nurses is now recognized as a major occupational health problem in United Kingdom (UK), Europe, Australia, and throughout North America. Cooper and Swanson reported that 5% of healthcare workers in Finland have experienced bullying. In a survey of National Health Trust community workers in the UK, 38% of staff reported having experienced bullying and were likely to leave their job as a result, whereas 42% had witnessed the bullying of others (Cooper & Swanson). Chiders (2004) noted in “The Nurses in Hostile Work Environment’s 2003 Report” that bullying is very prevalent in hospitals and workplaces across the United States (US) to the extent that 70% of victims leave their job, 33% of these victims leave for health reasons and 37% because of manipulated performance appraisals. After much study Cooper and Swanson concluded that workplace bullying is a significant, under-reported, and under-recognized occupational safety and health problem. This section will now discuss the origins of workplace bullying.

...newly employed nurses may observe and embrace the bullying behaviors of other nurses just to fit in, thus contributing to the continuation of bullying behavior.The problem of bullying may have its origin in individual, environmental, and/or organizational factors. Individual factors include mental illnesses, female gender workers, and drug and alcohol habits. Environmental factors include poor lighting, lack of safety measures, and working with violent or hostile patients and families. Organizational factors include lack of resources, understaffing due to the nursing shortage, poor workgroup relationships, changes in composition of work groups, low supervisor support, increased workload, downsizing, and organizational restructuring (Cooper & Swanson, 2002; Salin, 2003).

Research completed on nurses in the UK has suggested that bullying behavior among nurses is a learned process (Lewis, 2006). For example, newly employed nurses may observe and embrace the bullying behaviors of other nurses just to fit in, thus contributing to the continuation of bullying behavior. This was evidenced in Lewis’ findings related to pain management. Lewis found that some nurses strive for freedom from traditional ways of pain management and question traditional pain management regimes that sedate the patient every four hours, regardless of the patient’s perception of their pain. Rather these nurses prefer to allow patients to have input into their pain control needs. This difference of opinion as to the degree of patient control over their pain management sets up an opportunity for inter-professional conflict and cliques which become favorable reference groups to which nurses aspire when looking for acceptance. Lewis has argued that these nursing cliques may become vehicles in which bullies may hide, gain support, and use the organizational bureaucracy to their personal advantage as they find strength in being a member of their chosen clique.

Researchers Chaboyer, Najman, and Dunn (2001) found that Australian nurses continue to be an oppressed group that uses bullying tactics as they interact with each other. Hutchinson, Vickers, Jackson, and Wilkes (2006a) also studied Australian nurses and noted that informal organizational alliances enabled bullies to control work teams using emotional and psychological abuse to enforce bully-defined rules. To illustrate these findings Hutchinson et al. (2006b) cited their qualitative study of 26 nurses who had personal experiences of bullying. This study explored the nurses’ perspectives regarding the meaning of bullying, beliefs about bullying, and perceptions of bullying, so as to interrupt the bullying process at both rural and metropolitan Australian hospitals. Hutchinson et al. (2006b) found that nurses worked together to control the team “through ignoring, denying and minimizing bullying; indoctrinating nurses into bullying-defined rules; and structuring those they considered weak” (p. 228). Hutchison reported that the nurses’ stories revealed bullying-defined rules on the nursing unit enforced the hierarchical separation of labor with aspects of “militarism, public humiliation, and tactics of exclusion” (p. 228). These narratives revealed that bullying on nursing units is normalized through a “Process of Indoctrination” as the bullying breaks a nurse’s physical and psychological strength and confidence. Hutchinson et al. (2006b) maintained this either forces the nurse to resign or accept the bullying rules of survival, and commented that these resignations serve no purpose other than adding to the nursing shortage

The Nature of Workplace Bullying

Some time ago, when I had taken a new nursing position, I observed, and became concerned about the frequent bullying behaviors I was observing among the nurses. My concern regarding this bullying behavior prompted me to begin journaling about these behaviors, as is my custom when situations puzzle me, in an attempt to better understand what was happening. In reading through my journal entries I realized these behaviors centered around three main themes: Interactions, Power Disparities, and Actions. The Table describes some of the bullying behaviors I had observed.

Lewis (2006) observed that bullies are fully aware of their actions, although actions such as these are difficult to pinpoint, often occurring behind closed doors. Anthony (2006) and Stevenson, Randle, and Grayling (2006) made similar observations while studying bullying behavior directed towards student nurses. Sometimes students experienced destructive innuendo, criticism and resentment, humiliation in front of others, undervalued efforts, and/or teasing. At other times they were ignored and frozen out. Although students felt like failures if they did not understand something, they tolerated the bullying so they would fit in.

Consequences of Workplace Bullying

Hutchinson et al. (2006a) documented workplace bullying as lasting from six months to seven years, and reported that nurses targeted by bullies frequently find themselves labeled as stupid or less capable. These nurses then become the focus of attention while the bully goes unnoticed, making the actions of the bully legitimate because the built-in power structures claimed by the bully serve to normalize the abuse. Salin (2003) observed that large organizations with lots of formality and lengthy decision-making processes make excellent shelters in which bullies may hide and go unrecognized. Meanwhile, the victim, and others, may suffer from isolation, fear, and/or stress-related illnesses, or commit suicide. Each of these possible consequences will be described below.

Isolation

Lewis (2004) conducted in-depth interviews of 10 nurse managers working in the U.K.. National Health Service and found that bullies isolated their victim and created a climate of fear in an attempt to make the injured party feel inadequate. Lewis reported that nurses witnessing this bullying behavior were reluctant to speak out lest doing so result in their own censure. Lewis also observed that nurse managers lacked skills, training, and knowledge of how to deal with bullying events, and that complaints of bullying often went unnoticed by the managers. Lewis also noted that managers had an ambivalent attitude towards policies and procedures addressing bullying in the workplace. This lack of managerial skills and commitment to addressing workplace bullying contributed to unsatisfactory outcomes of bullying cases. Lewis concluded that bullies are highly devious individuals, who are well aware of their actions. Swedlund (2004) also observed the isolation experienced by the victim noting, “What people need to learn about is the complete isolation of bullying.…The whipping boy is hit by people while others just stand around.…The person being bullied sees the whole world against him…He’s totally isolated” (para. 5).

Fear of Going to Work

Lutgen-Sandvik, Tracy, and Alberts (2006) reported that a target of bullying often faces work with the thoughts of “impending doom and dread.” For example, a bullied nurse often fears going to work and is secretly ashamed of being bullied, but is confused as to how to fight back. Lutgen-Sandvik et al. found that with the passing of each day the bullied nurse retreats into silence while others attack her or his person and workplace reputation. Cooper and Swanson (2002), Patten (2005), and the Workplace Bullying Institute (2003) all noted that self-doubt takes over at this point and stifles the nurse’s innovation and initiative, resulting in psychological and occupational impairment

Stress-Related Illnesses

Victims of bullying may show symptoms of nausea, headache, weight loss, insomnia, anxiety, depression, alcoholism, irritability, loss of libido, self doubt, and Post Traumatic Stress Syndrome (PTSS) (Canadian Initiative on Workplace Violence Website, 2007; Gilmour & Hamlin, 2005; Hoel, Faragher & Cooper, 2004; Jackson, Clare, & Mannix, 2002; Knight, 2004). A study done on healthcare professionals in the UK (Hoel et al.) concluded that one in five people being bullied at work exhibit symptoms of PTSS, such as hyper-arousal, feelings of constant anxiety, over-vigilance, avoidance of traumatizing events, and flashbacks. Other research on nurses in the UK (Patten, 2005) has shown that between one-third and one-half of stress-related-sickness absenteeism results from workplace bullying. Patten found that this stress often results in nurses giving up or having fractured careers with serious implications both personal (loss of financial security) and organizational (loss of a valuable employee).

Suicide

Even more serious than stress-related illnesses is stress-related suicide. Hastie (2007) described one young Australian midwife who had entered nursing in 1995 with enthusiasm, passion, and commitment. This midwife had experienced hostility, criticism, and intimidation in her practice, which eventually lead her to taking her life by asphyxiation. Although this event occurred over ten years ago in Australia, Canada is presently reporting one out of seven adult suicides results from workplace bullying (Workplace Bullying Institute, 2003).

Witnesses of Bullying

Bullying affects not only the victim; but also the witness (Patten, 2005). The witness begins to wonder if she or he is next. Subsequently, self-esteem decreases, erodes, and gives way to depression and anger for nurses who witness bullying. Patten found that this kind of depression and anger could lead nurses’ spouse or partner(s) to see a decline in their partner’s “thirst for life.” Patten reported that divorce, loss of marital affection, and diminished attention to one’s children can result from workplace bullying.

Canadian Legal Response Related to Workplace Bullying

...most nurses have only a minimal knowledge of these Canadian Anti-Bullying laws.International attention to workplace bullying has led Canadian lawmakers to look more fully at bullying and establish laws related to bullying. Lewis and Lawson (2004) have noted the following changes in Canadian laws related to bullying:

  • The Canada Labor Code amended its 2000 regulations requiring the employers to take prescribed steps to prevent and protect workers from workplace bullying.
  • British Columbia, Alberta, and Saskatchewan amended their Occupational Health and Safety Acts to attend to workplace bullying.
  • Ontario gave workers the right to refuse unsafe work; nurses arguing harassment under the Ontario Health and Safety Board may find their case referred to the Human Rights Commission for resolution.
  • The Canadian bill C-45 holds corporations, senior officers, and directors criminally liable for reckless endangerment of the safety of staff in the workplace.
  • Canadian law now states that nurse victims of workplace bullying who develop mental or physical illness may be entitled to compensation under Workers’ Compensation legislation.

However, my personal observation has been that most nurses have only a minimal knowledge of these Canadian Anti-Bullying laws. No specific legislation exists in Manitoba, Yukon, North West Territories, Nunavut, Ontario, New Brunswick, Nova Scotia, Newfoundland or Labrador regarding workplace bullying, but General Duty obligations exist under Occupational Health and Safety Legislation whereby employers must provide a good working environment for its employees (Canadian Initiative on Workplace Violence, 2007).

Strategies to Support Victims of Workplace Bullying

In spite of the fact that bullying is unacceptable and healthcare managers are expected to ensure a respectful work environment for nurses, workplace bullying continues to exist among nurses. An important person in stopping this bullying is the individual involved! However, when these victims of nurse-to-nurse bullying decide they have had enough of “going to war every day,” they will need support from within and outside the organization that enables them to maintain a positive attitude within themselves while successfully dealing with workplace bullies (Patten, 2005). The ability of the nurse to stop this bullying can be enhanced by both support and counseling.

...workplace bullying continues to exist among nurses.Tim Field has developed a support program to strengthen a positive attitude about workplace bullying (Field Foundation, 2005). In 1994 Tim Field, a Customer Services Manager in the UK, suffered a mental breakdown when bullied out of his job. As a result, in January 1996 Field set up the U.K. National Workplace Bullying Advice Line, and in 1998 established a Bully On-Line Website. Before his death in 2006, Field lectured throughout the world and received an honorary doctorate for his initiatives to stamp out worldwide bullying (Bullying On-Line Website, 2005). The Field Foundation remains committed to working for a world free of bullying through activities, research, and education. The Canadian branch of the Field Foundation, the Anti-Workplace Bullying Support Group, located in Vancouver, British Columbia, meets monthly to share information pertaining to bullying laws and regulations in British Columbia and to raise awareness of bullying within the province. The ultimate goal of this group is to facilitate changing attitudes about bullying in the workplace.

Although I found no mention in the literature of any healthcare region in Canada having support groups specifically for nurses experiencing workplace bullying, many healthcare regions throughout Canada do have Employee Assistance Programs that provide counseling. For example, the Vancouver Island Health Authority (VIHA) confidential Employee and Family Assistance Program is a program that nurses can access regarding problems that affect work life and general well-being (VIHA, 2007). Counseling is also available to nurses through their family physician and community mental health services.

Strategies to Prevent Workplace Bullying

Nursing leaders can play an important role in communicating that bullying behavior will be replaced with respect...The Canadian Initiatives on Workplace Bullying (2005) found a need for nurse leaders to understand the relationship between nurse-to-nurse bullying in the workplace and economic costs associated with nurse resignation. Nursing leaders can play an important role in communicating that bullying behavior will be replaced with respect, while the perpetrators of bullying behavior receive help, thus creating a safe working environment for nurses. This elimination of workplace bullying includes education, policy, and celebration.

Education

The first step in teaching nurses how to decrease bullying by others is to help them understand what to do and what not to do when confronted by a bully. Beech (2000) found that to reverse bullying behavior and keep nurses in the workforce nurses must support one another. Beech noted one of the major mistakes nurses make when confronted by a bully is to try to reason with the bully and help the bully understand their position. However, being nice to a bully only confirms the bully’s superior beliefs. Beach found that the bullying occurs as bullies gather compliant co-workers around them and devise strategies to get rid of those who are less compliant. Beech encourages nurses to never resign, because their resignation would mean that the bully had won. Rather Beech encourages nurses to keep a file of what is happening to them as they may be required to produce this evidence months in the future.

The first step in teaching nurses how to decrease bullying...is to help them understand what to do and what not to do...being nice to a bully only confirms the bully's superior beliefs. Nurses are encouraged to become involved in developing anti-bullying programs that teach the principles of bullying avoidance. The Canadian Center for Occupational Health and Safety (2007) has suggested the following content be considered in these programs:

  • Definition of workplace bullying
  • Legal obligations
  • Anti-bullying prevention policies
  • Bullying assessment
  • Developing preventive measures
  • Reporting and investigating

A formal evaluation of a program, conducted by a third party not directly responsible for the implementation of the program, can provide objective evidence of the effectiveness of the anti-bullying program (Canadian Centre for Occupational Health and Safety, 2007).

Policy

Involving nurses in policy development gives them the opportunity to take ownership and responsibility for the environment in which they work. Involving nurses in policy development gives them the opportunity to take ownership and responsibility for the environment in which they work. Enabling nurses themselves to develop a  policy addressing workplace bullying is one strategy to decrease bullying. Such a policy should target positive behavior and work towards creating a working climate that treats nurses with dignity, respect, and fairness (Tehrani, 2005). Tehrani states that the aims of an anti-bullying policy should strive to accomplish the following outcomes:

  • Ensure the dignity at work of all nurses
  • Respect and value differences among nurses
  • Make full use of the talents of all the nurses
  • Prevent acts of discrimination, exclusion, unfair treatment, and other demeaning behaviors
  • Demonstrate a commitment to equal opportunities for all nurses
  • Display open and constructive in communication
  • Handle conflict with creativity
  • Show fair and just behavior when dealing with other nurses
  • Become educated about nurse and employer responsibilities
  • Develop positive behaviors

A policy such as this can enhance the self-concept of the workgroup itself, thus strengthening group members to prevent bullying within the group.

Celebration

Celebrating positive, bully-free work environments can also decrease bullying behaviors. Bullying Awareness Week provides an excellent opportunity for nurses to celebrate a positive work environment. Bullying Awareness Week is for adults as well as for schoolchildren. The expectation of the Canadian Psychological Association is that Bullying Awareness Week will raise the awareness of bullying in Canada (Service & Cohen, 2007). National Nurses Week is a yearly celebration in Canada and elsewhere. During this week of celebration, nurses may also learn of opportunities to become leaders, innovators, and pioneers in anti-bullying initiatives (Canadian Nurses Association Website, 2007).

The Nurse Manager’s Role in Addressing Workplace Bullying

Nurse managers have an important role to play in preventing and correcting nurse-to-nurse bullying so as to keep as many nurses as possible in the nursing workforce. Nursing shortages for the future have been projected around the world (The Canadian Institute for Health Information, 2006; Fulcher, 2007; Horan, 2007; Stevens, 2002). Stevens, and also Pearce (2001), have noted that intimidation of nurses by other nurses in the workforce is exacerbating the nursing shortage. Nurse managers have an important role to play in preventing and correcting nurse-to-nurse bullying so as to keep as many nurses as possible in the nursing workforce. Ruggiero (2004) recommended visible participation of nursing leadership in addressing bullying so as to foster commitment, participation, trust, and open communication with front-line workers. Briles (2003) found that managers who acknowledged and addressed workplace bullying were able to effectively help healthcare organization retain good employees. Nursing leaders can do this by establishing an ombudsperson within the healthcare organization to whom nurses can complain without fear of backlash. Nursing leaders can also decrease bullying by promoting teamwork and team building among nurses to promote flexibility, sensitivity to the needs of others, and encouragement of creativity within the group. Teamwork and enhanced productivity is achieved when the group members have a strong sense of belonging and loyalty to the group and the organization. When implementing strategies to address nurse-to-nurse bullying, nurse managers should endeavor to create a culture of change. The new culture will require an understanding of bullying and its implications and the establishment of guidelines for acceptable work behavior and peer interaction (Field, 2005). Additionally, a Dignity at Work Policy, which includes sections on harassment, discrimination, violence, and bullying, can highlight the employer’s commitment to provide workers with employment that is free from acts of bullying and intimidating behavior.

Conclusion

...programs and policies need to be developed to address bullying... [and it] must become unfashionable. The problem of nurse-to-nurse bullying in the workplace has gained considerable attention as nurse leaders struggle to recruit and retain nursing staff. As role models and creators of the work group culture, nurse leaders play a key role in combating bullying in the workplace. It is not enough to simply help the victims; rather programs and policies need to be developed to address bullying behaviors. Bullying must become unfashionable. Education, policy development, celebration and support encouraged a whole generation of smokers to “butt out.” The same efforts must be initiated to stop bullying in the workplace.

 

Table. Examples of Nurse-to-Nurse Bullying

Communication Description
Interactions
  • Withholding information.
  • Posting documentation errors on bulletin boards for all disciplines to view and others to critique.
  • Intimidating others by threats of disciplinary procedures.
  • Writing critical and abusive letters or notes to co-workers.
  • Verbalizing harsh innuendos and criticism.
  • Using hand gestures to ward off conversation.
  • Rolling eyes in disgust.
  • Having personal values and beliefs undermined.
Power Disparities
  • Using shift/weekend charge positions to direct/control staff assignments/breaks.
  • Controlling co-workers’ behavior by reporting them to their supervisors for perceived lack of productivity and assistances.
  • Placing others under pressure to produce work and meet impossible deadlines.
  • Withholding knowledge of policies and procedures to get co-workers in trouble.
Actions
  • Yelling at co-workers.
  • Demanding co-workers answer the telephone, NOW!
  • Refusing to mentor and guide new staff in their practice.
  • Refusing to help those who struggle with the unknown and uncertainty.
  • Refusing to help others in need of assistance.
  • Giving public reminders of incomplete/missed documentation or work.

 

Author

Carol F. Rocker MHS, BN, RN
E-mail: carolrocker@shaw.ca

Carol Rocker is a nurse with 30 years of experience in the Canadian healthcare industry. She has worked over the years as a staff nurse, nurse manager, and nurse educator. Carol is currently working with emergency, medical, surgical, and pediatric patients while completing a Doctoral Health Administration degree at the University of Phoenix. Carol’s dissertation addresses the health and wellness of the healthcare workers.

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©2008 OJIN: The Online Journal of Issues in Nursing
Article Published August 29, 2008


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