Just culture model and psychological safety support staff and patient safety.

WORKPLACE BULLYING in critical care settings is more than a cultural concern—it’s also a patient safety risk with potential legal consequences. Critical care units, inherently high-stakes environments, require precision, coordination, and trust among staff. Yet nurse-to-nurse bullying—particularly toward new or transitioning staff—remains a persistent challenge in many units. In some cases, these behaviors are minimized or reframed as “tough love,” unit culture, or necessary teaching rigor.

Workplace bullying has the potential to diminish teamwork, create communication breakdowns, and lead to negative organizational outcomes that compromise the quality of patient care. In high-acuity environments, even subtle communication breakdowns may result in serious consequences that could erode team cohesion, contribute to attrition, and threaten patient continuity and institutional credibility.

When communication failures lead to patient harm, healthcare organizations may face liability exposure, regulatory scrutiny, and reputational damage. Nurse bullying in critical care environments affects clinical outcomes and presents legal risks. Practical leadership strategies and actionable guidance for frontline nurses, grounded in best practices, can help address these impacts.

Real-world consequences

Psychologically unsafe work environments create the potential for increased moral distress, emotional exhaustion, and burnout among frontline nurses. Beyond the emotional toll, bullying has tangible consequences. Hostile work environments can directly impact cognitive function, judgment, and communication—all essential to safe patient care.

For example, a new ICU nurse unsure about a procedure may avoid asking for clarification out of fear of ridicule or reprimand, potentially resulting in delayed interventions, incomplete documentation, or other patient safety risks. The resulting adverse events can become the subject of internal and external review. In litigation, plaintiff attorneys frequently request documentation of complaints, staff turnover, and preceptorship evaluations to assess institutional accountability. When hospitals lack a system to address repeated complaints about a specific preceptor, they increase their liability exposure. Such incidents may contribute to staff turnover, communication breakdowns, and increased regulatory scrutiny when organizations fail to address repeated reports of workplace hostility.

Just culture and psychological safety

Psychological safety may offer opportunities to support nurse resilience, enhance stronger team communication, and improve patient outcomes. The Just Culture model provides organizations with a structured framework to distinguish among human error, at-risk behavior, and reckless conduct, supporting accountability while avoiding a culture of blame.

In practice, nurse leaders, risk management teams, and quality departments carry responsibility for initiating Just Culture review processes after adverse events or reported concerns. Rather than defaulting to individual discipline, these reviews assess whether interpersonal dynamics, bullying, or inadequate support contributed to the incident.

Edmondson and Lei define psychological safety as the belief that one can speak up without fear of punishment or humiliation. Critical care units benefit when staff feel safe to express concerns, ask questions, and admit mistakes. Leaders who cultivate psychological safety reduce the likelihood of preventable harm and improve unit resilience.

By formally embedding Just Culture principles and psychological safety standards into organizational policy, healthcare leaders create clear reporting pathways, standardized review processes, and defined accountability structures. Integrating these practices into orientation, preceptorship programs, performance evaluations, and incident investigations ensures consistent application of evidence-based bullying prevention strategies in everyday clinical practice. This policy alignment not only protects staff but also fulfills leaders’ duty of care to patients, supports regulatory compliance, and reduces an organization’s liability exposure.

Best practice frameworks

Legal and regulatory frameworks increasingly emphasize the importance of addressing disruptive behavior in healthcare environments. According to the National Council of State Boards of Nursing, state boards have the authority to review workplace conduct when interpersonal behavior contributes to unsafe clinical practice or patient harm. In some situations, hostile preceptorship or ineffective communication can contribute to documentation delays, medication errors, or other breakdowns in care. While individual nurses remain accountable for their actions, regulators also may scrutinize organizational cultures that allow known disruptive behaviors to persist (See Best practice chart)

Case law also highlights how hospitals have been held liable for not intervening in toxic work environments. Courts increasingly examine hostile work environment claims when healthcare organizations fail to address repeated complaints of workplace harassment or bullying.

These cases stress the legal expectation that healthcare organizations foster not only physical but psychological safety—especially during vulnerable transition periods like onboarding or cross-training.

Ethical considerations and moral distress

Nurse bullying isn’t only a cultural and legal issue—it’s a direct ethical violation. The American Nurses Association Code of Ethics for Nurses clearly states that nurses must “create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect.” Bullying undermines these principles and creates an environment where ethical nursing practice becomes difficult, if not impossible.

In addition, nurses experiencing bullying may endure moral distress, a psychological condition that arises when a nurse knows the ethically appropriate action to take but feels powerless to act due to organizational constraints. New nurses may feel complicit in suboptimal care when organizations discourage them from speaking up or asking questions.

This persistent moral injury contributes to burnout, disengagement, and ultimately detachment from both patients and peers—costs that healthcare systems can’t afford. Over time, moral distress contributes to emotional exhaustion and depersonalization. By failing to protect staff, organizations risk compounding moral distress, increasing turnover, and ultimately compromising patient safety and trust.

Failure to address hostile workplace behavior increases legal exposure for healthcare organizations. Ignoring the ethical dimensions of bullying can expose healthcare organizations to lawsuits that allege negligence, unsafe working conditions, or even discrimination. Ethics and law intersect when patterns of mistreatment go uncorrected, turning a cultural issue into a regulatory and legal crisis.

The Occupational Safety and Health Administration requires employers to provide a workplace free from recognized hazards, a duty increasingly interpreted to include psychological safety when patterns of harassment are documented. Title VII of the Civil Rights Act prohibits discrimination that creates a hostile work environment; bullying tied to race, gender, or another protected class escalates liability risk.

State nurse practice acts affirm nurses’ right to practice in environments that support safe clinical judgment, and the Joint Commission requires accredited hospitals to implement and enforce policies that promote a culture of safety. Legal and regulatory standards cited in policy but not meaningfully enforced put organizations at risk for regulatory penalties, litigation, and reputational harm.

How nurse leaders can intervene

State boards of nursing and national accrediting organizations have begun to recognize the impact of workplace behavior on patient safety. The Joint Commission has long recognized that disruptive behaviors undermine a culture of safety, a position reinforced through multiple Sentinel Event Alerts and leadership standards. The Joint Commission’s leadership standards require healthcare organizations to address disruptive behavior, and the American Nurses Credentialing Center’s Magnet Recognition Program® includes measures of nursing autonomy and work environment as part of its criteria.

Organizations that fail to align their bullying policies with these standards risk losing accreditation or facing scrutiny during site visits. Moreover, organizations can be cited for regulatory violations if bullying behavior contributes to adverse events or staff turnover that compromises patient care. Nurse executives and compliance officers must review their policy language and ensure that it incorporates reporting mechanisms, staff education, and defined corrective actions.

Failing to align with regulatory expectations opens the door to civil litigation, labor grievances, and board sanctions. A legally sound antibullying policy must clearly define unacceptable behaviors, include timely response protocols, and demonstrate consistent enforcement.

Nurse leaders have a pivotal role in shaping workplace culture and enforcing accountability. Intervention starts with a zero-tolerance policy for bullying that’s clearly communicated and consistently enforced.

Beyond policies, leaders should implement training on topics like unconscious bias, feedback delivery, and psychological safety. Leadership rounding offers an opportunity to observe interpersonal dynamics in real time and allows staff to report concerns without fear of retaliation. Additionally, implementing structured preceptor programs, with defined learning objectives and scheduled check-ins, ensures that preceptors are held to measurable standards. These programs should include 360-degree evaluations and input from preceptees. If a nurse expresses discomfort with a preceptor, it should trigger a formal review.

Organizations that incorporate feedback mechanisms, such as monthly anonymous surveys, can identify patterns and intervene early. Leaders must understand that failure to respond to documented bullying complaints can expose organizations to claims of negligent supervision, hostile work environment, and regulatory violations. When patterns of mistreatment are reported but not investigated or corrected, organizations risk being viewed as deliberately indifferent, which significantly increases liability exposure.

Thorough documentation of complaints, investigative steps, and corrective actions serves as more than a best practice; it provides a critical safeguard in potential litigation and regulatory review. In addition, change sustainment requires proactive culture audits and peer-review accountability systems.

What frontline nurses can do

Although leadership accountability is essential, frontline nurses also play a critical role in interrupting bullying behaviors and safeguarding patient care. Frontline nurses, frequently the first to experience or witness incivility, can influence both unit culture and patient outcomes. Any comprehensive antibullying framework must emphasize empowering frontline nurses with clear, actionable strategies.

Organization leadership should encourage frontline nurses to document bullying behaviors objectively and contemporaneously, including dates, times, witnesses, and specific conduct. Neutral, factual documentation strengthens internal reporting processes and provides critical evidence if concerns escalate to human resources, compliance, or regulatory review. Documentation should focus on observable behaviors and their impact on patient care or workflow, rather than subjective interpretations.

Nurses should have access to established reporting pathways without fear of retaliation. These may include charge nurses, nurse managers, ethics committees, or anonymous reporting systems. Organizations that normalize early reporting reduce the likelihood that hostile behaviors will become entrenched or lead to adverse events. When bullying interferes with communication, handoffs, or clinical decision-making, reporting becomes not only a professional right but a patient safety obligation.

Frontline nurses should receive education on the importance of chain-of-command escalation when bullying threatens safe care. Escalation isn’t punitive; it’s a protective mechanism designed to ensure prompt action of clinical concerns. Nurses who understand and appropriately use escalation pathways demonstrate professional accountability and reduce personal legal risk.

Participation in shared governance, peer support initiatives, and civility training allows frontline nurses to proactively influence unit norms and workplace culture. Active nurse involvement in shaping practice environments presents opportunities to strengthen psychological safety and improve staff retention. By engaging in these structures, frontline nurses help foster a culture where speaking up is expected, supported, and protected.

By equipping frontline nurses with these tools, healthcare organizations reinforce ethical practice, reduce legal exposure, and strengthen patient safety. Effective bullying prevention involves responsibility shared across leadership and frontline staff.

Implications for nursing practice

In addition to near-term interventions, nurse leaders must consider long-term strategies for creating sustainable, healthy work environments. These include incorporating bullying prevention into annual competencies, leadership training programs, and new hire orientation. Organizations should regularly update their policies to align with state nursing board recommendations and national accreditation standards.

In addition, future research should explore the effectiveness of different intervention models, including mentorship programs, restorative justice circles, and third-party mediation. Multi-site studies could help identify which strategies yield the best outcomes in various healthcare settings. Understanding the cost–benefit of anti-bullying programs also could help justify investment to organization administrators and policymakers.

Without systemic change, nurse bullying will continue to threaten patient safety and increase organizational liability. Long-term planning must include transparent policy development, regular climate assessments, and leadership accountability to drive cultural transformation.

The culture of silence and normalization around bullying must be replaced with one of transparency and accountability. Nurse educators and leaders must integrate bullying prevention into ongoing competency evaluations and ethics discussions. Nursing schools also can play a role by preparing students to recognize and respond to hostile behavior.

Ultimately, bullying prevention supports the Quadruple Aim of healthcare: better outcomes, lower costs, improved patient experience, and enhanced clinician well-being. Regulatory agencies increasingly evaluate staff culture and workplace safety during audits, and leadership teams must prepare to present both qualitative and quantitative evidence of their efforts. Organizations with strong antibullying frameworks frequently see reduced turnover, improved patient safety scores, and higher staff satisfaction. Furthermore, these environments are more likely to attract top talent and maintain Magnet® recognition or other accolades.

Workplace bullying prevention isn’t simply a task for HR or compliance officers—it’s a strategic priority that requires full engagement from executive teams, clinical leadership, and frontline nurses.

Do what’s right

Preventing nurse bullying is more than an internal morale issue; it’s a risk management and patient safety imperative. With growing regulatory oversight and public awareness, healthcare organizations have an obligation to take meaningful steps to prevent, detect, and respond to bullying behavior—especially in high-stakes critical care environments. Leaders must move beyond reactive measures to invest in proactive education, monitoring, and policy alignment.

By creating psychologically safe units, supporting robust mentorship, and enforcing clear expectations, organizations can foster a culture where every nurse feels valued and protected. This approach doesn’t just reduce liability; it also elevates care delivery, improves retention, and aligns with the highest standards of professional practice. Creating safer workplaces starts with leadership accountability, organizational courage, and a commitment to doing what’s right—not just legally, but ethically and professionally.

Kelli Lam is the founder of Lam Legal & Clinical Solutions in Palm Springs, California. She is a critical care nurse and Juris Doctor whose work focuses on healthcare compliance, patient safety, and workplace culture in high-acuity clinical settings.

American Nurse Journal. 2026; 21(5). Doi: 10.51256/ANJ052658

References

American Nurses Association. Code of Ethics for Nurses. nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/

American Nurses Association. Position statement on workplace violence. nursingworld.org/globalassets/practiceandpolicy/nursing-excellence/workplace-violence–ana-position-statement.pdf

Arnetz JE, Hamblin L, Ager J, et al. Underreporting of workplace violence: Comparison of self-report and actual documentation of hospital incidents. Workplace Health Saf. 2015;63(5):200-10. doi:10.1177/2165079915574684

Edmondson AC, Lei Z. Psychological safety: The history, renaissance, and future of an interpersonal construct. Annu Rev Organ Psychol Organ Behav. 2014;1:23-43. doi:10.1146/annurev-orgpsych-031413-091305

The Joint Commission. Sentinel Event Alert 40: Behaviors that undermine a culture of safety. July 9, 2008. jointcommission.org/en-us/knowledge-library/newsletters/sentinel-event-alert/issue-40

Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers. 2016. osha.gov/sites/default/largefiles/OSHA3148.pdf

U.S. Equal Employment Opportunity Commission. Enforcement and litigation statistics. eeoc.gov/data/enforcement-and-litigation-statistics-0

Key words: nurse bullying, psychological safety, patient safety, workplace culture