An Upstanding Approach to Address Bullying in Nursing

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HEALTHY NURSE An upstanding approach to address bullying in nursing

Learn how to become more comfortable with speaking up.

By Cynthia Clark, PhD, RN, ANEF, FAAN

What hurts the victim most is not the cruelty of the oppressor, but the silence of the bystander. —Elie Wiesel

In the end, we will remember not the words of our enemies, but the silence of our friends. —Martin Luther King Jr.

GALLUP consistently rates nurses as having the highest standards of honesty and ethics among professions assessed by U.S. adults. Despite this impressive designation, acts of incivility and bullying persist within nursing, partly because individual workplace bullying incidents aren’t addressed. (See Bullying and group of professionals from intervening on its impact.) Sometimes nurses (and other their colleague’s behalf? Why did they assume healthcare professionals) don’t speak up be- the role of bystander? To understand their lack cause they don’t want to “get involved” even of response, let’s take a closer look at what it when the situation is serious, they worry means to be a bystander or an upstander. about retaliation, or they don’t know what to say. This article describes a bullying scenario, What’s a bystander? including the lack of response to the situation Various terms are used to describe by- by those close to it, why some individuals standers including witnesses, observers, ac- don’t speak up, and how to become an “up- complices, and indirect victims. Regardless of stander” (rather than a bystander). the term, bystanders’ actions and inactions, whether intentional or not, contribute to the The case of the demeaning colleague outcome of an uncivil or bullying event. By- Allison*, a nursing instructor, was upset after standers see, hear, or know about incivility, witnessing bullying behavior during a recent bullying, or other forms of workplace aggres- faculty meeting. According to Allison, Barbara, sion happening to someone else. They react a tenured faculty member, openly humiliated a to bullying behaviors in different ways. Some novice faculty member by making demeaning side with the offender by laughing at the sit- and condescending remarks, verbally chastis- uation; others give silent approval by simply ing her, and calling her worthless. When Alli- looking on or doing nothing to intervene. In son was asked how she and other faculty some cases, bystanders aren’t sure if the be- members responded, she said, “We didn’t say havior is serious enough to address. Howev- anything, we just let it happen. Honestly, I was er, the harmful impact of incivility and bully- just glad she wasn’t targeting me.” ing sometimes isn’t felt until after behaviors In this scenario, more than two dozen fac- become patterned or persistent over time. In ulty members avoided addressing the situa- other words, a single behavior may seem tion. What might have kept a highly educated inconsequential if the bystander hasn’t ob-

MyAmericanNurse.com September 2020 American Nurse Journal 31 signed the most challenging patient load and Bullying and its impact least-desired shifts), or being the only person in the group to act. Sometimes the bully may The American Nurses Association defines bullying as repeated, unwant- be protected by the organization and the wit- ed harmful actions intended to humiliate, offend, and cause distress ness who reports the incident may be asked in the recipient, and as a very serious issue that threatens patient and to “let it go” because the offender is otherwise nurse safety. Bullying behaviors take many forms, including: a “good nurse.” • engaging in rude or disrespectful verbal or nonverbal behaviors

• spreading rumors and negative gossip • making demeaning and abusive comments What’s an upstander? • withholding vital information Upstanders respond and speak up when bul- • cyberbullying or posting disparaging comments on social media. lying behavior or acts of mistreatment or intimidation occur. They speak up and take ac- Workplace bullying is associated with negative outcomes, such as: tion to stop the offender and support the • work dissatisfaction person being harmed or harassed. Evidence • turnover • intent to leave suggests that when witnesses take safe and ef- • treatment and medication errors fective action to support a bullying target, the • delayed care offender is more likely to stop the behavior. • patient harm. Becoming an upstander begins with taking a personal stand against incivility and bullying Bullying interferes with teamwork, collaboration, and communica- behavior and making it clear to coworkers tion, all essential to the provision of accurate, timely, and safe patient care. The documented harmful impact of incivility, bullying, and other that you won’t accept or participate in unde- forms of workplace aggression on nurse and patient outcomes should sirable workplace conduct. You can do this by serve as a resounding call to action for all healthcare professionals at setting a positive example—refuse to engage all levels of the organization. in negative gossip or spreading rumors, to laugh at off-color jokes or distasteful comments, to post offensive social media photos served similar behaviors occurring in the past. and messages, or to conspire to disrespect or The detrimental impact of bullying behav- marginalize a coworker. iors on bystanders is clear—observing acts of Upstanding doesn’t come easily. Many peo- workplace aggression directed toward a ple worry of reprisal or retaliation, becoming a coworker can compromise physical and men- target themselves, or being labeled a complain- tal health. Similar to workplace bullying tar- er, troublemaker, or whistleblower. These con- gets, bystanders may develop symptoms of cerns can be assuaged when an organization’s guilt, anxiety, and depression; in some cases, leadership establishes clear definitions of ac- they may disengage or leave an unhealthy tions that constitute retaliation and policies workplace altogether. against it, educates supervisors and managers about how to respond to bullying reports, and Why do bystanders stand by? takes visible action when legitimate bullying re- Reasons for not intervening when bullying be- ports are made. Part of that education includes haviors occur are as varied as the individuals ensuring leaders understand that because of involved. They include: confidentiality issues, a general statement may • fear of retaliation (personal and professional) be made to the person reporting the problem to • lack of administrator and/or organizational assure them that steps are being taken to ad- support dress the issue, but details can’t be shared. • lack of clear policies or guidelines to address workplace bullying and other forms Addressing the scenario as an upstander of aggression In the opening scenario, many people wit- • belief that addressing the situation makes nessed the bullying behavior, but no one matters worse spoke up. Perhaps some individuals were • feeling powerless to make change fearful of retaliation or maybe they were wait- • lack of skills or confidence to address the ing for someone else to step in and help. situation. What would an upstander do? Many bystanders fear being the next target, If the faculty and staff had co-created and being treated unfairly (for example, being as- agreed on team norms with built-in accounta-

32 American Nurse Journal Volume 15, Number 9 MyAmericanNurse.com bility measures to address disrespectful be- es with Interpretive Statements states that nurs- haviors, an upstander might refer to those es at all levels of the organization have an eth- norms to address the situation. For example, ical and moral obligation “to create an ethical if speaking respectfully had been established environment and culture of civility and kind- as a team norm, an upstander might say, ness, treating colleagues, coworkers, employ- “We’ve all agreed to speak respectfully with ees, students, and others with dignity and re- one another; we’ll get more accomplished if spect…and that any form of bullying, we deal with issues in a professional manner.” harassment, intimidation, manipulation, threats Some teams establish catch phases or team or violence will not be tolerated.” slogans to use when addressing uncivil situa- Fulfilling this provision requires healthcare tions, such as “That’s not who we are,” “That’s leaders throughout an organization to set a not how we roll,” or “We’re better than this.” clear, compelling vision for civility, respect, Another approach is addressing the person inclusion, and collaboration among all mem- engaging in uncivil behavior by name and bers of the organization. making a direct request in the moment. State • Resources must be dedicated to raising firmly and respectfully, “Barbara, disrespectful awareness and educating all healthcare pro- remarks impact our ability to foster a team en- fessionals about the negative impact of inci- vironment; please speak to us in a respectful vility on people, workplaces, and patient way.” Using an evidence-based conversation care while simultaneously reinforcing and framework, such as Preview, Advocacy, Advo- building on existing organizational strengths. cacy, Inquiry, and Listen (PAAIL), is another • Positive role modeling at all levels of the or- effective way to address an uncivil situation ganization is essential. To ensure individuals either in the moment or later in a private set- intervene, leaders must model the way and ting. The structure for PAAIL is as follows: reward those who speak out against bully- Preview: I’d like to talk to you about _____. ing and other forms of aggressive behavior. Advocacy: I saw (or heard, or noticed...) • Ongoing education and practice sessions _____. are required to help frontline nurses effec- Advocacy: I’m concerned because ______. tively address workplace bullying. Inquiry: I wonder what was on your mind • Talking about how to address bullying isn’t at the time? enough. Role-playing and debriefing after Listen: Listen carefully and intentionally to uncivil or bullying situations and using evi- the response. dence-based approaches to becoming an up- Here’s an example of using PAAIL to ad- stander must be implemented and reinforced. dress the uncivil faculty member: “Barbara, I’d • Sharing stories about witnesses who have like to talk about what happened in today’s constructively intervened to address prob- meeting. I noticed that you raised your voice lematic behavior affirms their success and and spoke in a disrespectful tone. I’m con- portrays them as ordinary people who cerned about the impact on our team. What choose to make a difference and as role are your thoughts about what happened in models we can emulate and celebrate. the meeting?” The upstander then listens carefully to Barbara’s response before continuing Follow the trusted leader the conversation. Upstanding is challenging because each situation is unique and complex, and stepping in isn’t It takes a village easy. Most individuals express a desire to inter- Upstanding requires skill, courage, and sup- vene, but they lack the appropriate skills. You port from the organization. Without organiza- can hone your upstander skills (communication tional support, nurses may stay silent as a self- and conflict negotiation) by participating in on- protective measure. In organizations where a line and in-person training workshops and role- positive work culture is fostered and rein- playing experiences that build resilience and fos- forced and where upstanding behavior is re- ter collegiality and high-performing teams. warded, nurses are more empowered to speak Leaders can support upstander behaviors up and more likely to intervene when con- by implementing and widely disseminating fronted with a bullying situation. The Ameri- clearly defined policies to prevent and ad- can Nurses Association Code of Ethics for Nurs- dress workplace bullying, instilling a culture

MyAmericanNurse.com September 2020 American Nurse Journal 33 of zero tolerance for all forms of workplace American Nurses Association. Position statement: Inci- violence, rewarding upstander behaviors, and vility, bullying, and workplace violence. July 22, 2015. co-creating and reinforcing team norms that nursingworld.org/practice-policy/nursing-excellence/offi- cial-position-statements/id/incivility-bullying-and-work- reflect the organization’s vision, mission, and place-violence shared values. Reports of incivility and bullying must be taken seriously by supervisors Clark CM. Creating & Sustaining Civility in Nursing Edu- cation. 2nd ed. Indianapolis, IN: Sigma Theta Tau Inter- and human resources representatives, and national Publishing; 2017. thorough, confidential investigations should Clark CM, Fey MK. Fostering civility in learning conver- protect all parties identified in the report. sations: Introducing the PAAIL communication strategy. Trusted leaders who model the way and Nurse Educ. 2020;45(3):139-43. demonstrate upstander behaviors will likely Edmonson C, Zelonka C. Our own worst enemies: The find they have a trove of loyal followers. AN nurse bullying epidemic. Nurs Adm Q. 2019;43(3):274-9.

*Names are fictitious. Houck NM, Colbert AM. Patient safety and workplace bullying: An integrative review. J Nurs Care Qual. 2017; Cynthia Clark resides in Boise, Idaho, and is the strategic nursing 32(2):164-71. advisor for ATI Nursing Education, based in Leawood, Kansas. Keashly L. Ombuds and bystanding: Embracing influ-

ence. J Int Ombuds Assoc. 2018:1-18. researchgate.net/ References publication/330450038_Ombuds_and_Bystanding_Em- American Nurses Association. Code of Ethics for Nurses bracing_Influence with Interpretive Statements. 2015. nursingworld.org/ practice-policy/nursing-excellence/ethics/code-of-ethics- Reinhart RJ. Nurses continue to rate highest in honesty, for-nurses/coe-view-only ethics. Gallup. January 6, 2020. news.gallup.com/poll/ 274673/nurses-continue-rate-highest-honesty-ethics.aspx American Nurses Association. Issue Brief: Reporting In- cidents of Workplace Violence. 2019. nursingworld.org/ Rowe M. Fostering constructive action by peers and by- ~495349/globalassets/docs/ana/ethics/endabuse-issue- standers in organizations and communities. Negotiation brief-final.pdf Journal. 2018;34(2):137-63.

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