To the public, the nursing profession exemplifies caring and compassion. Yet bullying may exist in all areas where nursing is practiced. From “eating our young” to sabotaging and scapegoating nurse colleagues, bullying is a serious problem that jeopardizes unit morale and patient safety.

What’s in a name?

“My preceptor rolled her eyes and looked at me like I was stupid every time I asked her a question. I finally stopped asking. Doesn’t she realize I’ve only been a nurse for 3 weeks?”

The young playground bully who resorted to physical means to show superiority has grown up. Now he or she uses psychological or social behaviors to cause harm in more subtle ways in the workplace.

Bullying is defined as “repeated, offensive, abusive, intimidating, or insulting behaviors; abuse of power; or unfair sanctions that make recipients feel humiliated, vulnerable, or threatened, thus creating stress and undermining their self-confidence.” Depending on the situation, bullying may be termed horizontal hostility, lateral violence, hazing, relational aggression, or workplace incivility. When the bully is on the same authority level as the victim (as when a nurse bullies another nurse or a manager bullies another manager), the behavior may be termed horizontal hostility or lateral violence. Of course, bullying also may take the form of aggressive behavior by superiors toward subordinates.

Common bullying behaviors used by nurses include innuendo, verbal affront, undermining, withholding information, sabotage, infighting, scapegoating, backstabbing, failing to respect privacy, and breaking confidences. Such behaviors as gossiping, exclusion, eye-rolling, silence, and humiliation also may qualify as bullying. Whatever we call it, the concepts and behaviors are similar.

Origins of a bully culture

Although bullying exists in all professions, the problem seems especially prevalent in nursing. In a survey of more than 4,000 critical-care nurses, 18% reported they’d experienced verbal abuse by another nurse. About 25% rated the quality of collaboration among registered nurses (RNs) as fair or poor, and 22% rated respect for other RNs as fair or poor.

Approximately 65% of respondents in a survey at a large medical center said they frequently observed horizontal bullying behaviors among coworkers. What’s more, up to 70% of nurses who were bullying victims left their jobs; in contrast, one-third of those with health problems left their jobs because of those problems. Roughly 60% of new RNs quit their first job within 6 months of being bullied, and one in three new graduate nurses considers quitting nursing altogether because of abusive or humiliating encounters.

A vicious cycle

Sociological literature shows that oppressed group members tend to act out against one another because they lack control over their situation. They can’t verbalize frustrations or concerns to higher-ups for fear of punishment. Inability to express feelings and concerns diminishes their self-esteem. Powerlessness further lowers their self-esteem and triggers the cycle of oppressed group behavior undertaken to boost self-esteem—which in turn causes more frustration, lack of coworker support, and conflict.

In many healthcare facilities, administrative hierarchies promote and perpetuate oppressive conditions, such as inability to take uninterrupted breaks or meals, inadequate staffing ratios, limited supplies, and little recognition of nurses’ ability to think critically. These conditions contribute to the problem.
Bullying behaviors differ by gender. Males more often express aggression physically or by working their way into positions of power. Females tend to use more cerebral means, such as defamation, humiliation, and betrayal of trust.

Survivor syndrome

Nurses who survive bullying early in their careers tend to carry their learned behaviors with them. They accept the bully culture as part of the job and eventually choose one of two paths: leave the unhealthy work environment in search of a healthier one, or participate in the culture either as a bully or bystander.

Effects of workplace bullying

Bullying creates a toxic work environment with serious consequences for victims, institutions and, ultimately, patients. Victims feel isolated from other team members. They may dread going to work. Their self-esteem decreases and their self-doubt suppresses their initiative and innovation. Eventually, they become impaired psychologically and occupationally. Many new nurses lack confidence to begin with and require positive feedback about their performance; bullying makes them feel invisible, incompetent, and inferior. (See Generational clashes by clicking the PDF icon above.)

Bullying victims may suffer stress-related health problems, such as nausea, headache, insomnia, anxiety, depression, weight changes, and alcohol and drug abuse. Research on bullied nurses in the United Kingdom indicates workplace bullying accounts for a third to one-half of stress-related absenteeism. In Canada, one in seven adult suicides results from workplace bullying.

Bullying affects bystanders as well, making them wonder if they’ll be the bully’s next victim; this stress can lead to depression and anger. What’s more, if they decide to report the abuse, they may fear retaliation and a “whistleblower” reputation—fears that shield the bully from discipline.

Financial burden of bullying

Bullying erodes job satisfaction and morale, in turn increasing absenteeism, lowering productivity, and promoting high staff turnover. Given the high cost of hiring and orienting new nurses, losing nurses within the first year creates a tremendous financial burden on institutions.

“Our new manager didn’t like me from the start. Within a month, she was assigning me more and more extra tasks until I couldn’t get them all done. When I tried to talk to her about my workload, she said I should be able to handle it because I was the one with the master’s degree. Later she fired me, stating I didn’t meet our department’s expectations, even though I had several complimentary letters from patients and other managers.”

Low work satisfaction also decreases patient satisfaction, which can affect reimbursement and patients’ likelihood to recommend the facility.

A threat to patient safety

Bullying reduces patient safety by interfering with teamwork, communication, and collaboration. When a nurse manager withholds information, purposely assigns too heavy a patient load, or doesn’t provide assistance when needed, patient safety in that unit may decrease and potentially fatal errors may occur. (See Is your manager a bully? by clicking on the PDF icon above)

Nurses who’ve been bullied feel isolated from coworkers; they’re reluctant to ask questions and afraid to speak up to advocate for patients. High nurse turnover jeopardizes continuity on the unit, and may leave nurses without adequate experience or knowledge to recognize and act quick­ly on potential patient problems.

Creating a healthy work environment

As in most dysfunctional situations, the first step toward change is admitting a problem exists. If bullying has long been accepted as the norm, the problem may be hard to recognize. Education is crucial; understanding the reasons for bullying and associated behaviors can help nurses realize they’re capable of stopping the oppression. Nurse leaders can benefit from learning how to identify and curb bullying behaviors. Also, learning effective communication strategies helps nurses respond to bullying in a positive manner.

Individual efforts can make a big difference in promoting the culture change.

Nurse managers and chief nursing officers have an important role in breaking the bullying cycle and maintaining the new culture. They should encourage staff to report bullying incidents, ensure that those who experience and report abusive incidents will be safe from retribution, and take action to discipline bullies, counsel victims, and implement corrective measures to prevent recurrence. Bullying can be addressed by unit-based councils, with council members serving as role models for other staff members.

Zero-tolerance policy

To end abusive behaviors, hospitals must implement clear zero-tolerance policies. The message must be communicated loudly and clearly from upper administration that the bullying culture must exist no more.
In 2004, the American Association of Critical-Care Nurses issued a public policy statement that serves as a clear mandate for facilities to adopt a policy to end abusive and disrespectful behavior. In 2008, the Center for American Nurses released a position statement on lateral violence and bullying in the workplace that calls for promoting a culture of safety that encourages open, respectful communication. Also, the Joint Commission has issued leadership standards that include creating processes for managing bullying behaviors and adopting a code of conduct for staff.

Bullying and other abusive and disruptive behaviors in nursing must end. The destructive effects reach out in all directions to create unhealthy, unsatisfying work environments. Treating all members of the healthcare team with respect leads to collaboration, open communication, and teamwork and promotes delivery of the high-quality care we all strive for. We can break the cycle of bullying and abuse through individual accountability, a mentoring culture, and support for our nursing peers.

Selected references

Center for American Nurses. Position Statement: Lateral violence and bullying in the workplace. 2008. http://www.nursingworld.org/Bullying-Workplace-Violence. Accessed November 14, 2011.

Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. 2008 July 9;40:1-3.

Vessey JA, Demarco RF, Gaffney DA, Budin WC. Bullying of staff registered nurses in the workplace: a preliminary study for developing personal and organizational strategies for the transformation of hostile to healthy workplace environments. J Prof Nurs. 2009 Sep-Oct;25(5):299-306.

Terri Townsend is a critical-care nurse and faculty member at Indiana University Health Ball Memorial Hospital and Ball State University School of Nursing in Muncie, Indiana.