Even though nursing is a profession of caring and compassion, bullying exists in many forms in it. Bullying threatens teamwork, morale, communication, and, most important, patient safety. The playground bully from our childhood has grown up to become our nursing colleague who is now bullying in the workplace (See Workplace bullying). It’s easy to understand when the phrase “eating our young” is used in relation to bullying aimed at nursing students or novice nurses; however, it is important to acknowledge that bullying also targets older, experienced nurses.
Workplace bullying is “repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators. It is abusive conduct that is threatening, humiliating, or intimidating, work interference … or verbal abuse,” according to social psychologist and anti-workplace bullying activist Gary Namie, PhD. Bullying is also referred to as horizontal hostility, incivility, and lateral violence. Although the definitions for these terms differ, all describe bullying behavior. According to the Dr. Namie’s Workplace Bullying Institute, 65 million American workers are affected by bullying. Bullying affects nurses of all ages and all levels of experience.
Bullying behaviors fall on a continuum ranging from eye-rolling and exclusion to humiliation, withholding information, scapegoating, intimidation, and backstabbing. These behaviors are deliberate. The bully sets out to destroy the victim’s confidence and credibility as a way to gain power and control. Bullying can last for months or even years. In a study of Australian nurses and bullying behaviors by Hutchinson and colleagues, the respondents reported three forms of bullying: personal attack (isolation, intimidation, and humiliation), erosion of professional competence and reputation (damaging professional identity and limiting career opportunities), and attack through work roles and tasks (obstructing work or economic sanctions). One-third of the study participants eventually left their positions because of bullying.
According to the 2010 Health Resources and Services Administration (HRSA) Registered Nurse Study, the median age of a registered nurse (RN) is 46. Forty-five percent of practicing RNs are age 50 and older, and 15.5% are age 60 and older. Even though the nursing workforce is growing and expected to increase by 500,000 in the next 10 years, there is a projected shortage of RNs in the United States that will top 260,000 by 2025. The HRSA projects that more than 1 million RNs will reach retirement age within the next 10 to 15 years. With a serious nursing shortage expected only to worsen, nursing as a profession can ill afford to lose any more nurses to bullying.
Seasoned nurses possess a great deal of knowledge that is gained only from experience. Although much has been done to recruit recently graduated nurses, current research is shifting to examine what can be done to keep valuable seasoned nurses in the workforce. Aside from modifying the physical environment by using safe patient-handling equipment and providing a more ergonomic workplace, an important factor influencing the continued tenure of experienced nurses is the organizational culture, or healthiness of the work environment. Older nurses who are the victims of a bully are more likely to experience burnout and lack of support, which contributes to their likeliness to leave an employer.
Why bully the older nurse?
Of course, bullying crosses all generational lines. Baby Boomers can engage in behaviors toward younger nurses in an effort to make them “pay their dues,” or see if a new nurse will fit in. The same traits that older, experienced nurses tend to possess—a sense of personal strength, a degree of competence, and an air of success with a “been there-done that” attitude—can also make them a target for bullying. Bullies lack self-confidence, have low self-esteem, and may even lack competence in their role. The experienced, competent nurse is seen as a threat in the bully’s eyes, and thus becomes their target. In addition, the bully may have been a target at one time, and became a bully in response.
Generational differences may influence relationships between nursing colleagues. Currently, nurses in the workplace are from three different generational groups: Baby Boomers (born 1943 to 1960), Generation Xers (born 1961 to 1981), and Millennials (born 1982 and later). Although the following characteristics of these groups are general in nature, understanding them is an important aspect to establishing healthy work environments and improving nurse retention. Of course, it’s important to consider each person as an individual. For example, a Baby Boomer may be expert with technology, while a Millennial may shun it.
- Baby Boomers are thought of as workaholics who derive part of their identity from their occupations. They illustrate professionalism and value autonomy in their work, yet they desire loyalty and recognition from their employers. They are generally slow to adjust to technology, but they appreciate creativity and new ideas.
- Generation Xers grew up in homes with working parents and have a strong sense of independence; they do not tend to require external support or approval. Generation Xers became familiar with computers at an early age, and know how to integrate information from a variety of sources. They do not necessarily value traditional educational tracts. They strongly value the work-life balance, and are creative and confident.
- Millennials have just started entering the workforce in the last decade. They are the first generation to have spent their entire lives around computers. They obtain much of their information via technological devices. Millennials respond well to positive feedback, and tend to leave if they perceive the work environment is unhealthy.
Younger nurses can bully older nurses by treating them as if their knowledge is antiquated, “washed up,” or out of step with the times. Older nurses can be excluded from social activities in the unit, made fun of for physician limitations, and ignored by the younger nurses. Ellie, a nurse for over 30 years, relates, “Last week, I came out of my patient’s room. Several of the younger nurses were talking about a new product trial that was going to start the next day. I asked one of them about it, and she said, ‘You should have paid attention during the morning huddle. You might need to turn up your hearing aid battery.’ She walked away, laughing with one of the other nurses. I felt humiliated and embarrassed.”
In her book, Toxic Nursing, Cheryl Dellasega describes the “Super Nurse.” This nurse feels the need to call attention to her own abilities and alienate all others on the team as a way to demonstrate she is knowledgeable and in control of the situation, at the expense of collaboration and teamwork. Dellasega describes the Super Nurse’s behavior as a symptom of fear and insecurity rather than superiority, and when directed at an older nurse reflecting fear and insecurity about having less experience than a more seasoned colleague. Liz, a staff educator for critical care units, describes such a situation with one of her orientees:
“I was teaching a group of new graduates in the ICU about intracranial pressure monitoring. My primary background of expertise is in cardiology, but I had developed a neurological class that included hands-on practice. I consulted with the equipment company, which had excellent teaching materials for me to use. After the class was over, one of the new graduates sent an e-mail to her manager about how I should not teach this class because I was not an ICU staff member, and could not possibly know anything. She further stated that she could have figured out how to set up the equipment without the class, and it was a waste of time. I thought that was a passive-aggressive way to discredit my experience and expertise. She never said anything in class and gave me no indication she felt she was wasting her time.”
When the bully is the boss
The Workplace Bullying Institute’s 2014 Workplace Bullying Survey reports that 56% of respondents who had been bullied stated that the perpetrator was a manager or supervisor. A recent study of 6,500 RNs by Estes indicated nearly 47% were victims of abusive supervision. Factors that contribute to managerial bullying include organizational instability due to downsizing, restructuring, or frequent changes in managers; autocratic or laissez faire leadership styles; oppressed-group behaviors; or a well-entrenched bullying culture. Organizations that focus on productivity and financial outcomes alone can reward nurse managers for bullying their way to meeting goals, consequently instilling the perception that bullying behaviors are necessary for career progression.
When it comes to managing by bullying, the ends do not justify the means. Managers who bully often learn by example, and may themselves have been victims of a bully in the past. Over time, they rise through the ranks, using bullying behaviors as a means to acquire perceived power. Managers who bully tend to have low self-esteem or low clinical competence and target staff members who are competent, well-liked, or receive special recognition. “Our new manager decided that I was getting too old to take care of most of the cardiac surgery patients,” said Debbie, an experienced nurse. “He announced in a staff meeting that he was going to have several new nurses trained to take care of the open heart patients. He said I needed to ‘pick up the pace’ and turn over the reins to the younger nurses. I felt like he had no respect for my experience and knowledge.”
Nurses with many years of experience are experts in their areas of nursing, able to analyze and quickly act on complex patient situations. Their life experiences also enhance their empathy for patients and families, which can increase patient satisfaction with the hospital experience. In uncertain economic times, some managers may see only the financial aspect of their human resources. The older nurse may find himself or herself to be a target of a bullying boss because he or she commands a much higher salary than a new graduate. Julie relates:
“Our new unit director began bullying staff almost from the moment she started here. Her favorite tactic was to label nurses as toxic, then make up stories about them to get them in trouble. She went after everyone who had an opinion, and when pressed, she said things changed at our hospital because of the merger with the new health system. In the first 18 months of her regime, our 18-bed unit lost 14 nurses, all with more than 5 years of experience. It added up to over 180 years of nursing knowledge. Now, there are so many ‘newbies’ that it scares me to come to work. They are smart, and will be good some day, but they lack that intuitive skill that is gained only from experience.”
The effects of bullying
Nurses who are bullied suffer myriad consequences including psychological effects such as depression, inability to focus on tasks, anxiety, sleep disturbances, burnout, and post-traumatic stress disorder. According to a 2013 study by Longo, older nurses suffer greater physical effects of bullying, including headaches, cardiovascular disorders, gastrointestinal disorders, and musculoskeletal problems. In addition, older nurses experience shame and humiliation when they witness episodes of bullying of other staff members. In a recent survey by Dumont of 955 RNs, 82% reported experiencing at least one bullying behavior either weekly or daily. Nurses ages 41 to 50 experienced bullying most often and also suffered the highest rate of adverse effects. Victims of bullying at all ages have higher absenteeism and may exhibit decreased productivity due to stress and the distraction of trying to stay out of the bully’s way.
Patients aren’t immune to bullying’s consequences. When the work environment is toxic, there is a breakdown in communication, teamwork, collaboration, and leadership. When nurses aren’t comfortable asking for help, they are more likely to make errors. Adverse patient outcomes, and even patient mortality, increase in settings where workplace bullying occurs. According to the American Association of Critical-Care Nurses, unhealthy work environments contribute to increases in hospital-acquired conditions and patient readmissions. These adverse patient outcomes, along with poor patient satisfaction scores, also result in decreased financial reimbursement. Increased nurse turnover decreases continuity of care and communication.
Incivility and bullying have adverse outcomes for organizations as well. Incivility-associated losses in productivity (due to absenteeism, impaired time management, diminished physical ability, and decreased quality of work) were measured in a 2008 study by Hutton and Gates of 145 RNs with a mean of 9 years of experience. The results indicated a mean annual financial cost of productivity loss totaling more than $1,400 per person. In addition, nurse turnover adds to the financial burden of an organization. The average cost of replacing one seasoned nurse can be as high as $64,000, according to Walrafen et al. It is also difficult to recruit nurses to work at an organization with a bullying culture.
To sum up, bullying has adverse effects on the victim, the patients, and the organization. Older nurses may be experiencing some age-related physical limitations, which are compounded by the effects of bullying. Hospitals experience higher-than-normal nursing turnover and its many associated expenses. Poor patient quality and dissatisfaction lead to decreased financial reimbursements, which also adversely affects an organization’s bottom line. Failure to meet patient safety benchmarks can also affect accreditation as well as financial status.
Breaking the bullying cycle
Many national organizations have taken a stand against bullying. The Joint Commission issued a Sentinel Event Alert in 2008 requiring hospitals to create a code of conduct and a process for managing inappropriate behaviors. All team members must be held accountable for modeling professional behaviors, and managers must be provided with skills-based training on communication, relationship building, and collaboration.
In 2015, the American Nurses Association released the position statement “Incivility, Bullying, and Workplace Violence,” which states, “All registered nurses and employers in all settings, including practice, academia, and research must collaborate to create a culture of respect, free of incivility, bullying, and workplace violence.” The statement calls for evidence-based practices to address this type of negative behavior.
Training in effective communication and conflict resolution skills is key to starting to break the workplace bullying cycle. (See Ten steps to breaking the bullying cycle.) The first step in eliminating bullying is to admit the problem exists. Some bullying behaviors are subtle and less likely to be noticed (eye-rolling, silence). Older nurses may be entrenched in a work culture where bullying is accepted and therefore may believe it is futile to try to report it. Education of all staff on bullying behaviors helps develop an awareness of the problem and the implications of unchecked bullying. Any educational program must address both appropriate and inappropriate behaviors and any policies that exist to address them.
Ten Steps to Breaking the Bullying Cycle
Note: Educational resources, including infographics that can be downloaded, are available from the American Nurses Association at http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence
Communication with the bully also includes the manager, who can respond appropriately to reported bullying behaviors. Clearly communicating what the behavioral expectations are, and supporting bullies in efforts to change their toxic behaviors can go a long way toward changing the culture of the unit. Statements such as “I do not feel right talking about that person if she is not here” can stop gossiping in its tracks. Using strategies such as “I feel __ when you ___” are good ways to address bullying behaviors directly without being accusatory or aggressive. In some work environments, bullying behaviors are so entrenched that they have become the norm, so the bully may not even realize he or she is behaving inappropriately.
Bystanders often outnumber the bully, so there is power in numbers to prevent a minor problem from escalating into a bullying episode. Staff members must commit to creating a positive workplace culture, and vow to stop participating in negative and destructive behaviors. Remember, we encourage what we condone, and can deprive the bully of an audience if we do not buy into what the bully is saying or doing. Fostering a culture of respect can improve collaboration, teamwork, and communication, which will, in turn, promote an environment of patient safety.
Managers and nursing leaders are crucial in setting the overall tone for a nursing unit. Supporting a zero-tolerance policy with respect to bullying and acting on all instances of bullying will go a long way in demonstrating that victims are supported and the manager’s credibility is strong. If staff members see a lack of action on the part of a manager, they will grow to believe that the bully is really in charge and the behaviors will continue. By modeling professional behavior and skilled communication, managers can identify and manage bullies to ensure that the healthy work environment is maintained. Administrators must also ensure that the managers are not engaging in bullying behaviors by observation and creating an environment in which employees can safely report bullying and know that these issues will be addressed.
Getting rid of bullying
As the title of this article suggests, workplace bullying knows no age or experience level for its victims, targeting young and old nurses alike with repeated behaviors aimed at derailing a self-confidence, reputation, and career.
Bullying has adverse effects on the victim, the patients, and the organization. Older nurses may be experiencing some age-related physical limitations, which are compounded by the effects of bullying. Patients in a nursing unit with a bullying culture are deprived of teamwork and communication, and may suffer errors, healthcare-acquired conditions, and poor satisfaction. Hospitals experience higher-than-normal nursing turnover and its many associated expenses. Poor patient quality and dissatisfaction lead to decreased financial reimbursements, which also adversely affects an organization’s bottom line. Failure to meet patient safety benchmarks can also affect accreditation as well as financial status.
Education to identify bullying and how to manage it is vital to creating a healthy workplace, as well as establishing and enforcing zero-tolerance policies. By fostering a work environment that is built on trust, respect, teamwork, collaboration, and effective communication, bullying behaviors will no longer have a place in nursing.
American Association of Critical Care Nurses (AACCN) Position Statement. Zero Tolerance for Abuse. Aliso Viego, CA: AACCN;2004. www.aacn.org/WD/Practice/Docs/Zero_Tolerance_for_Abuse.pdf
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Terri Townsend is a staff educator for cardiovascular services at Community Hospital Anderson in Anderson, Indiana.