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The impact of bullying, and what needs to be done to eliminate it

Jun 01, 2011, By: Laura Eggertson

During the worst of the bullying, the only thing that kept Valerie* going was a nightly phone call from a supportive nursing colleague and a letter of reference from a doctor she worked with. The letter praised her skill, her knowledge and her clear, concise charting. “I would read that letter over and over, to remind myself of how I’d been,” says Valerie, choking up. “The place I work has stripped every bit of self-worth out of me.”

Valerie, an RN who works in a specialized health field in western Canada, has been bullied by nurses on her team and the manager for almost two years. The experience has left her hurt, scared, insecure and ready to quit. And she’s not alone.

In Canada, 44 per cent of female nurses and 50 per cent of male nurses report being exposed to hostility or conflict from people they work with, according to the 2005 National Survey of the Work and Health of Nurses. The survey was conducted by Statistics Canada in partnership with Health Canada and the Canadian Institute for Health Information.

Twelve per cent of the RNs, licensed practical nurses and registered psychiatric nurses who responded to the survey experienced emotional abuse from co-workers; however, experts in the field say that percentage is likely vastly under-reported. “It’s a problem at every single level of the entire profession,” says Kathleen Bartholomew, a Seattle-based RN and the author of Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other.

In the United States, it is estimated that 60 per cent of newly registered nurses leave their first job within just six months after experiencing some form of “lateral violence.”

In 2010, Toronto researcher Claire Mallette led a study on horizontal violence at the University Health Network. Of the 160 nurses involved in the study, 95 per cent had observed horizontal violence and 71 per cent identified themselves as targets. “Horizontal violence is absolutely alive and well in most, if not all, health-care organizations,” says Mallette, now director of the school of nursing at York University.

The dozens of nurses who responded to a call to readers in Canadian Nurse reported painful experiences of bullying in the workplace.

Bullying behaviour, says Bartholomew, ranges from negative gestures such as eye rolling or sighing to isolation techniques, gossiping, withholding information, forming cliques, refusing to work with colleagues or refusing to help them. Bullying can also include direct sabotage of a nurse’s career by outright lying about that person’s performance.

In Valerie’s case, one nurse who bullies her refuses to share information. When Valerie asks a question, the bully responds, “I had to figure things out for myself; you figure it out, too.” Other times, she simply refuses to speak to Valerie.

This attitude has spread to Valerie’s manager, who questions her competence, blames her for errors and speaks to her in a demeaning way, repeating things like, “Have you got a memory problem, or something?” At one point, the manager forced Valerie to sit through a month of remedial charting sessions with a colleague, who subsequently told Valerie there was nothing wrong with her charts.

The experience left Valerie feeling “humiliated and degraded.” Worse, it triggered the same kinds of emotions she had felt when she was sexually abused as a young girl. “Bullying is very much like sexual abuse in a family,” she says. “You don’t want to talk about it — it’s a secret. You think it’s your fault. Everyone just keeps quiet, and there’s no freedom for the person who’s been abused unless someone actually speaks out.”

Speaking out is exactly what the experts say to do. Bartholomew advises nurses to recognize the bullying when it occurs, whether it is happening to them or to someone else. “What prevents most victims from speaking up is that they internalize the bullying and feel that it is deserved.” She urges victims to take time to calm down after an incident has occurred and then to confront the bully privately, articulating how the bully’s behaviour makes them feel.

“Use the ‘I’ word,” says Mallette. “As in ‘When you speak to me in this tone, I get very upset.’” She adds, “But you can’t just hope bullies will change. What you can change is the way you respond to them.”

Sometimes, however, confronting the bully or reporting the hostility to a supervisor doesn’t end the problem. That was the case for Nicole,* who received no support, even after telling her manager that she felt continually attacked by a charge nurse and that nurse’s friends at the city hospital ward where she worked. Instead, the manager assigned one of the bullying nurses to “buddy” her. “It was hell — it was absolute hell,” says Nicole. “I had a nurse sitting smack dab beside me, and I was questioned by her about everything.”

Nicole put up with being assigned her “buddy” for two weeks. Instead of having her self-confidence bolstered by a mentor, it was undermined by the continued second-guessing. She went to her union but, she says, “they weren’t terribly helpful.”

Ultimately, she asked her manager if he wanted her to stay. He told her it was time to think about Plan B: to leave. So Nicole gave up her dream job and returned to her old ward, where she cried every day. She is now off work, having been diagnosed with depression. “I feel like there’s a big part of my life missing, which is nursing,” she says. “It’s scary that somebody has that power.”

Bullying behaviour is often absorbed and ignored in workplace culture, or rationalized away, says Bartholomew, because some forms of aggression between nurses can be as subtle as the negative gestures one nurse will make when getting the staff assignment list. Even workplaces with prominently posted policies that stipulate the need for respect or that decry bullying frequently fall short in the face of actual complaints. The reality is that when no action is taken after a breach of policy is reported, people just stop reporting the behaviours.

One reason, says workplace relationship consultant Barb Fry, is that dealing with a bully is a lengthy, exhausting and sometimes frightening process for managers, since bullies may confront or threaten them, too. In the end, some managers opt to take the path of least resistance.

Fry, a Halifax RN, provides training and speaks about bullying. She has a special name for nurses who bully: workplace queens (or kings). Often, they are surrounded by an entourage of princesses (queens-in-waiting), who side with the queen against the chosen victim. And nurses who have been bullied themselves tend to view bullying as a kind of initiation that others, particularly new graduates or new members of a unit, must endure. When Fry was a nursing student at Dalhousie University in 1965, the expression “nurses eat their young” was, she says, already commonplace.

No end in sight

At 44, with 20 years of nursing experience, Kerry*thought the bullying she’d endured as a high school student in a small town in western Canada had been left far behind. Then she went to work in a city hospital.

One day, upset that a fellow nurse would not agree to come in 15 minutes early for two weeks to cover for her so she could take a two-week vacation, Kerry protested and began to cry.

A few minutes later, she apologized to the other nurse. But it was too late. For two years, the colleague froze Kerry out, refusing to speak to her unless it was absolutely necessary. “She openly ignored me, sabotaged me when there was no risk of getting caught and undermined my confidence every chance she had. I was daily fodder for gossip and slander around the lunch table.”

People took sides. The bully accused Kerry of making mistakes, called her lazy and publicly pointed out any errors she made. At an off-site meeting to resolve the issue, Kerry became the focus of all the blame. “Those days were a nightmare. The days she was away were the only ones I didn’t cry at work.”

Today, Kerry is always on guard and feels constantly judged. “I can’t make mistakes. I’m afraid to do anything wrong, and I question myself all the time.”

Bullying in her workplace has not ended. The bully, says Kerry, has simply directed her behaviour toward other nurses who have joined the unit more recently. “I work in fear that a small slip on my part will start it all over again for me. I worry that this time, her surreptitious sabotage will endanger a patient and end my career — that someday, she will win.”

She believes that hostility among nurses has been exacerbated by a management structure that has turned nurse leaders into bureaucrats and left few with the time or skills to interact with their staff on the front lines. She also faults organizational pressures, such as mergers among hospitals, health regions and municipalities, for increasing nurses’ levels of stress and feelings of powerlessness. “Because of those pressures, it’s safer for nurses to turn their frustrations on one another,” says Fry. “The tragedy is that there are other vulnerable people at the end of this: the patients. They are being denied the best of what nursing could give them.”

Bartholomew believes the causes of nurse-to-nurse bullying are even more culturally embedded, a result of the high expectations society places on nurses to be selfless caregivers.

Mallette, Bartholomew and Fry are joining a growing number of voices being raised from within the nursing profession to say that it’s time to change this workplace culture.

“The biggest thing I want nurses to know is that bullying is not OK,” says Bartholomew. “Tolerating the abuse helps to entrench it in the workplace — and that makes the environment unsafe for everyone.”

Bartholomew’s involvement in writing, counselling and educating on bullying in health-care environments was sparked by her own experience as a manager at a Seattle hospital. One day a nurse came to her to report the effects of being bullied. The nurse had overheard several colleagues making comments about her, like “She’ll never make a good nurse, will she?” and “She doesn’t have what it takes, does she?” The nurse was so upset that she inadvertently programmed a patient-controlled analgesia pump for morphine instead of Dilaudid. She told Bartholomew she was ashamed that she had let the remarks upset her so much that she had potentially endangered a patient’s life.

But Bartholomew assessed the blame where it needed to go: on the bullies. “Human beings can’t think straight when they’re upset,” she says. “Because of that bullying behaviour, someone almost died.”

The incident focused Bartholomew’s attention on the need for managers to spend more time on the floor observing interactions among staff. “My patients are only going to be as safe as my nurses are,” she points out, adding that taking sick days and stress leave is one of the few responses that some nurses have to on-the-job harassment. According to the 2005 National Survey of the Work and Health of Nurses, more than 22 per cent of nurses who reported experiencing low respect from their co-workers had been absent for at least 20 days in the year.

Samantha* has been a nurse for more than 30 years. She has been off work from her small Ontario community hospital for 18 months, after a year of experiencing harassment from a nurse manager. “I developed a disability as a result of the stress,” she says.

In Samantha’s case, the harassment included accusations that she had interfered with a doctor’s recommendation regarding a patient’s medication, questions about her judgment, threats of disciplinary action and assignments that increased her workload. The cause, she believes, was jealousy over the fact that she was more qualified than the manager and that her job enabled her to work days.

The issue has not been resolved, despite the fact that Samantha confronted the bully directly to express her feelings, made a complaint to the union and put in a request for arbitration. She feels completely unsupported by her organization, except for the doctors she has worked with. Even her union has suggested that she just retire. “I went through all the avenues of the hospital,” she says. “Everybody sort of pacified me — ‘OK, Samantha, you can talk to us about it’ — but nobody did anything about it.”

The result is that Samantha feels she has lost the career she loves. “Nursing has been my whole life, and she took it away from me,” she says of the bully.

Although nursing schools may provide some instruction about bullying, in Nicole’s case it consisted merely of getting the students to put on skits where they played the roles of the bullied and the bullies. But it takes more practice than participating in a few skits to learn how to cope with this kind of toxic environment, says Mallette.

In fact, the workplace culture itself needs to change. Organizations need to create policies, educate all their staff members about workplace harassment and violence, and begin enforcing those policies, says Mallette. Furthermore, focused training on how to cope with this behaviour is essential.

As part of their research, Mallette and colleagues at the University Health Network created a curriculum that includes a workbook, an e-learning module and an online role-playing scenario using the 3-D virtual world Second Life to help nurses practise ways to respond to a bully. Nurses participating in the study chose an avatar to represent them in the virtual world and then acted out different responses to bullying. “They loved it,” says Mallette. “They felt better able to recognize bullying and more confident in addressing it.”

Changing the workplace culture also requires managers and their supervisors to act immediately if nurses report bullying to them, and to back up nurses who have been hurt. Otherwise, says Mallette, the message is that they’re tolerating this type of behaviour.

The single most important thing nurses can do is to stop providing bullies with an audience, adds Bartholomew. “If you hear someone gossiping about a colleague, walk away. Better yet, speak up on that person’s behalf.” And when nurses witness a colleague being bullied? “Don’t be a silent witness.”

Resources recommended by Kathleen Bartholomew

Juice Inc. is a health-care consulting company that specializes in helping to change workplace culture. There are several good resources on the site about nurse-to-nurse hostility.

Roche, M., Diers, D., Duffield, C., & Catling-Paull, C. (2010).Violence toward nurses, the work environment, and patient outcomesJournal of Nursing Scholarship42(1), 13-22.

Rosenstein, A.H., & O'Daniel, M. (2008).A survey of the impact of disruptive behaviors and communication defects on patient safety. Joint Commission Journal on Quality and Patient Safety, 34(8), 464-471.

Stanley, K.M., Martin, M.M., Nemeth, L.S., Michel, Y., & Welton, J.M. (2007).Examining lateral violence in the nursing workforceIssues in Mental Health Nursing, 28(11), 1247-1265.

Vessey, J.A., DeMarco, R.F., Gaffney, D.A., & Budin, W.C. (2009).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 environmentsJournal of Professional Nursing25(5), 299-306.

Being a silent bystander is not, in fact, an option for nurses, says Fry. They have a legal responsibility and a professional accountability, based on their licences, to ensure that the standards of practice are in place. Those standards and the profession’s code of ethics require nurses to support one another to create a positive work environment.

When nurses exercise leadership to stop bullying, their interventions can work, says Emily McLeod, an advanced practice nurse at Toronto’s Sunnybrook Health Sciences Centre. She recalls attending a staff meeting on the topic of respecting colleagues when a new graduate knocked at the door, excused herself for interrupting and asked a team leader a question. In response, the team leader barked, “What’s your problem? Just take the report.”

McLeod saw the look on the new grad’s face. When the meeting was over, she nabbed the team leader and asked whether she’d thought about how she’d just spoken to the graduate. McLeod then brought the two nurses together. Fortunately, the graduate was strong enough to be able to tell the team leader that she’d felt she was bothering her and causing her frustration.

The encounter changed everything. The team leader apologized to the graduate — both in front of McLeod and again privately. McLeod’s intervention prevented what could have been the genesis of bullying. “Nurses need to be supported and trained to be assertive enough to communicate respectfully with one another and deliver helpful feedback,” she says.

A genuine investment in coaching and mentoring nurses on how to value and respect one another will pay off, not only for nurses, but also for the patients they serve.

*The names of those who have shared personal stories have been changed, at their request, to protect their privacy — and their careers.

Laura Eggertson is a freelance journalist in Ottawa, Ont.