Bullying New Nurses Laura R

Put a Stop to Bullying New Nurses Laura R. Flateau-Lux, BSN, RN, and Tammy Gravel, MSN, RN

ullying among nurses has been discussed in Early Exposure to Bullying the nursing literature for nearly two de- In the clinical setting today, nursing students are Bcades.1 The concept has been identified with exposed to bullying behavior early in their nurs- many terms, such as horizontal violence, lateral ing education. Stevenson, Randle, and Grayling violence, and relational aggression.2-4 All of these conducted a survey that measured the fre- can be best described as forms of psychological quency and types of bullying behavior among and social harassment perpetrated by one nurse 313 second-and third-year nursing students in against another through overt and covert behav- the United Kingdom during their last clinical iors.3,4 Examples of covert behaviors include placement. About 53% of nursing students in this nonverbal cues, deliberately withholding infor- study indicated that they’d experienced some mation, gossiping, and sharing private informa- form of bullying during their clinical placement tion that wasn’t intended for others to know. from physicians and senior members of the nurs- Overt behaviors are more blatant and include ing staff within specialty areas such as adult sabotaging another nurse, scapegoating, taking medicine, pediatrics, and mental health. The actions that prevent another nurse from doing most common behaviors indicated were being his or her job (such as hiding items needed for ignored/excluded (34%), experiencing destruc- patient care), forming cliques, and exhibiting tive criticism (30%), resentment (29%), and being passive-aggressive behavior toward a particular humiliated in the presence of others (29%).5 nurse.3 Simons set out to explore bullying experi- This article discusses the effects of bullying on enced by newly licensed RNs in Massachusetts nursing students and new graduate nurses enter- and its effect on intention to leave the workplace. ing the workforce and explores strategies for The target population for this study was nurses changing a culture of bullying on nursing units. who were newly registered and less experienced,

This article originally appeared in the Nursing2013 2013;43(6):24–28.

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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. because the researcher discovered from a litera- bullying against newly licensed RNs during their ture review that this population was the most first year of practice in New Zealand. The goals of vulnerable to bullying.6 Out of 511 survey re- the study were to identify the types and preva- spondents, 78% were grouped into the novice lence of bullying behaviors toward nurses within category (defined as nurses who’d had their their first year of practice, explore the impact of license for 36 months or less).7 Thirty-one per- these behaviors psychologically, understand the cent of respondents indicated that they’d been consequences of this behavior, and determine to bullied based on these criteria: On a weekly or what extent these new nurse graduates received daily basis over the last 6 months, the RNs expe- training to manage bullying. rienced at least two negative behaviors perpe- Out of the 1,169 questionnaires mailed, 551 trated by another nurse.6 respondents completed questionnaires for a re- The researcher additionally sought to mea- sponse rate of 47%. Results indicated that: sure the intention to leave the place of employment among those bullied. Simons found that • over 50% reported feeling that they were bullying had more influence on intent to leave being treated like a student than any other factor, including marital status, • 46% reported being given a lot of responsibil- race, and earned income. While the results of this ity without supervision study support the concept of bullying among • 34% reported being denied access to learn- nurses within the clinical setting, the researcher ing opportunities couldn’t conclude that bullying occurs more • 34% felt emotionally neglected often among newly licensed nurses within their • 20% indicated that they were told by another first 3 years of practice compared with experi- nurse that they’d endure repercussions for enced nurses who are newly licensed in Massa- speaking out against bullying behavior.2 chusetts by reciprocity from the sample provided by the Massachusetts Board of Registration in Several respondents reported psychological Nursing.6 consequences that included frustration, fear, de- At the end of this survey was an open-ended pression, anxiety, and mistrust. A few reported section for participants to provide any com- physical consequences, such as headaches, ments on the concept of bullying. Out of the weight loss, and fatigue. original 511 respondents, 184 nurses completed Forty-one percent of respondents indicated the comment section. In 2010, Simons expanded that they’d had some form of undergraduate on the original study using a qualitative design to training to help identify and manage interper- share the respondents’ experiences, as this fur- sonal conflict among staff. Only 13% indicated ther demonstrated the concept of bullying in the that they’d had some form of training to manage workplace. Four themes were identified in the interpersonal conflict since becoming an RN.2 stories provided by the respondents: structural bullying (perceived punitive and undue actions Repercussions During the First Year taken by supervisors), nurses eating their young, of Practice feeling out of the clique, and leaving the job. A review of the literature establishes that nurses Some of the most notable comments on these in the clinical setting experience bullying, both in four themes involved being given a workload that the United States and abroad. International stud- wasn’t manageable, feeling like senior nurses ies have further supported the concept that bul- took joy in keeping information to themselves at lying is most prevalent against new nurse gradu- the expense of the new nurse, feeling alienated, ates during their first year of practice. When a and intentions of leaving their job and/or the new graduate enters the workforce, his or her profession as a result.8 first real position creates an impression of the nurse’s role in healthcare.9 Bullying in the First Year of Practice A nurse’s first year of practice is a time for Most of the research on bullying among nurses acquiring new skills and knowledge and building with up to 1 year of experience has been con- confidence. New nurses are typically enthusias- ducted in the United Kingdom and New Zealand. tic about caring for patients and want to make a McKenna et al.2 conducted a classic study exploring difference in the world. They enter the profession

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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. with the assumption that they’re needed, yet some are greeted with behaviors from seasoned International studies nurses that can be psychologically distressing. have further supported The resulting interpersonal conflict, job conflict, the concept that bullying and stress leave the new nurse with a less positive impression about the role of a nurse. This is most prevalent against issue can create such a distraction that it com- new nurse graduates promises patient care.10 Research suggests that during their ﬁ rst year of bullying behavior must be exposed in order to stop it and to implement programs that allow practice. new nurse graduates to grow and develop confidence within their profession.2 with colleagues and others with a commitment to Nurse Retention and Patient the fair treatment of individuals, to integrity- Safety Issues preserving compromise, and to resolving conflict.”13 As the bullying phenomenon continues and im- Can this be said for the culture of nursing pedes the professional growth and development today? Fostering a culture that condemns bully- of newly licensed nurses, it may directly impact ing against nurses is an obligation for nursing staff retention. According to Griffin, after 6 leaders. months of employment, 60% of new RNs in the In January 2009, The Joint Commission issued United States quit their job due to some form of a set of leadership standards for all accredited bullying.3 organizations that require healthcare institutions Besides undermining the morale of new nurse to: graduates, bullying also compromises patient safety. Nurses who are bullied are less likely to • establish a code of conduct that addresses seek help and ask questions, potentially leading adverse behaviors in the workplace to errors and substandard patient care.11,12 • promote a nonpunitive forum that allows the To ensure patient safety and embrace an envi- reporting of such behavior ronment conducive to learning and patient cen- • create a disciplinary process for those who tered outcomes, any bullying must be addressed bully.14 and eradicated by establishing and enforcing zero-tolerance policies. Addressing and eliminat- Literature suggests that nursing leaders ing this culture of horizontal violence will raise should evaluate unit culture and become aware the profession of nursing by enhancing produc- of the signs of bullying in order to take swift ac- tivity and enthusiasm, reducing risks to patient tion in enforcing the cultural expectations that safety, supporting recruitment and retention, and support a code of professional conduct. Nurse strengthening nursing as an ethical profession. leaders should encourage seasoned staff on the unit to reflect on their first year of practice to Role of Professional Organizations enhance their mindfulness of the challenges and When interacting with peers, nurses are held to fears that new nursing graduates undertake when the standard of professional behavior by federal, entering the clinical setting for the first time.15 state, and local regulatory agencies and nursing organizations. A nurse declares his or her com- Measuring the Culture of a Workplace mitment to the profession by following the rules Environment and guidelines set forth by the American Nurses Several evidence-based studies suggest using Association (ANA) and state Board of Nursing. mentoring programs and establishing interdisci- For example, nurses have an ethical obligation to plinary groups to survey staff about work behav- act in accordance with provision 1.5 of the ANA’s iors to help enforce a zero-tolerance policy.16,17 Code of Ethics for Nurses with Interpretive State- Some tools and interventions that have been im- ments. In a section on relationships with col- plemented on nursing units to measure bullying leagues and others, it states: “The nurse main- are the Negative Acts Questionnaire—Revised tains compassionate and caring relationships (NAQ-R) and a cognitive-behavioral technique.3,18

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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. prevention approach. By raising awareness and Initiating Cultural Changes Within shining a spotlight on the stressors and oppres- 15 the Organization sive encounters that new nurse graduates will Nurse leaders have a direct responsibility to experience in the real world, educators can pre- set a standard of zero tolerance for horizon- pare them to respond appropriately and help tal violence. Strategies for meeting this goal eliminate these cruel customs.19 include: Education is the means by which nursing stu- • developing a unit/department-based code dents learn about the cultural and social aspects of conduct drafted in collaboration with of nursing.20 Educators could play an active role staff with expected behaviors targeting the in exposing nursing students to the phenomenon elimination of horizontal violence of bullying and teach behavioral techniques and • empowering staff to report/address peers skills that can be applied to nursing practice.10 who perpetrate horizontal violence without Every educational institution with a nursing pro- fear of retaliation gram has a responsibility as a whole to imple- • discussing any bullying incident at staff ment interventions at the course level to combat meetings, highlighting the behavior as bullying and positively influence job retention. horizontal violence The following are recommendations that edu- • providing staff with conflict management cational institutions could include within the skills and effective strategies eliminating nursing curriculum to empower nursing students horizontal violence to manage bullies and become advocates for • reinforcing and enforcing processes put in change3,19,20: place to address and eliminate incidences of horizontal violence. • Provide insight and prepare students for incidences of poor professional interactions with the necessary skills to manage these situations via simulation. The NAQ-R is a 22-item questionnaire that de- • Teach cognitive behavioral interventions scribes different types of bullying behaviors and that promote skill development of positive measures perceived exposure to bullying in the behavior when confronted with bullying workplace. The NAQ-R was used in the Massa- by using discussions, role playing, and chusetts study discussed earlier with good inter- feedback. nal reliability measured by the Cronbach alpha.6,18 • Enforce the importance of reporting bullying A helpful cognitive-behavioral technique is a behaviors that are witnessed by or perpe- strategy called cognitive rehearsal. Griffin con- trated against the nurse. ducted a study with 26 newly licensed RNs to • Educate students about the psychological measure the effectiveness of cognitive rehearsal consequences of bullying behavior, such strategies in confronting a bully in the workplace. as fear, frustration, anxiety, stress, and dis- This technique taught the new RN to respond dif- concerting feelings of wanting to leave the ferently to the behavior by rehearsing prototypi- nursing profession. cal responses to the most frequent forms of bul- • Teach coping skills necessary to combat lying, such as withholding information, raising of these stressors. the eyebrow, sabotaging, and backstabbing. By learning and practicing appropriate responses to Changing Cultural Norms bullying behaviors, the nurse is empowered to The existence of a culture that accepts bullying confront the bully. This strategy was proven must be recognized and challenged before strate- effective in the study and also raised awareness gies to eliminate this offensive behavior can be of inappropriate behavior in the workplace.3 implemented. Research suggests that this ac- knowledgement begins with individual nurses Academic Implications within the culture of the nursing unit.21 For strate- Awareness of the issue of bullying against new gies nurse leaders can use to eliminate bullying nurse graduates serves as a call to action among in the workplace, see Initiating Cultural Changes educational institutions to take a primary Within the Organization.

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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. In 2001, the American Association of Critical 6. Simons S. Workplace bullying experienced by Mas- Care Nurses set forth six essential standards that sachusetts registered nurses and the relationship they believed were required of acute and critical to intention to leave the organization. ANS Adv Nurs Sci. 2008;31(2):E48-E59. care nurses to promote a healthy working envi- 7. Benner P. From Novice to Expert: Excellence and ronment: skilled communication, true collabora- Power in Clinical Nursing Practice. Upper Saddle tion, effective decision making, appropriate staff- River, NJ: Prentice Hall; 2001. ing, meaningful recognition, and authentic 8. Simons SR, Mawn B. Bullying in the workplace— leadership.22 a qualitative study of newly licensed registered Nurses have a personal obligation to contribute nurses. AAOHN J. 2010;58(7):305-311. to their working environment and meet this stan- 9. Roberts BJ, Jones C, Lynn M. Job satisfaction of dard. Poor working relationships can be improved new baccalaureate nurses. J Nurs Adm. 2004;34(9): if all nurses make an effort to care about their peers 428-435. and take ownership of their role in workplace vio- 10. Stanley KM, Dulaney P, Martin MM. Nurses ‘eating lence. Nurses need to begin to support each other our young’—it has a name: lateral violence. S C Nurse. 2007;14(1):17-18. and confront the behavior. Nurses ought to come 11. Rocker CF. Addressing nurse-to-nurse bullying together to make it known that this behavior is not to promote nurse retention. Online J Issues Nurs. 23 acceptable and will not be tolerated. 2008;13(3). Addressing the issue of horizontal violence at 12. Brown L, Middaugh D. Nurse hazing: a costly reality. all levels, from entry level professional nursing Medsurg Nurs. 2009;18(5):305-307. education to organizational and departmental 13. American Nurses Association (ANA). Code of Eth- culture, will improve professional nurse satisfac- ics for Nurses With Interpretive Statements. Silver tion, patient outcomes, and organizational out- Springs, MD: American Nurses Publishing; 2001. comes, and support the retention of nurses as 14. The Joint Commission. Sentinel Event Alert: be- direct care providers. haviors that undermine a culture of safety; July 2008. 15. Longo J, Sherman RO. Leveling horizontal violence. Laura R. Flateau-Lux is an RN in a surgical/ Nurs Manage. 2007;38(3):34-37, 50-51. trauma ICU at Massachusetts General Hospital, 16. Gerardi D. Using mediation techniques to manage Boston, Mass. Tammy Gravel is an Assistant Pro- conflict and create healthy work environments. fessor and Director of Curriculum and Instruction AACN Clin Issues. 2004;15(2):182-195. at the School of Nursing, Massachusetts College of 17. Institute for Safe Medication Practices. Intimida- Pharmacy & Health Sciences, Worcester, Mass. tion: mapping a plan for cultural change in health- The authors have disclosed that they have no care (Part II). 2004. https://ismp.org/Newsletters/ financial relationships related to this article. acutecare/articles/20040325.asp. 18. Einarsen S, Hoel H. The Negative Acts Question- naire: development, validation and revision of a DOI:10.1097/NHH.0000000000000045 measure of bullying at work. Paper presented at 10th Annual European Congress on Work and Or- REFERENCES ganizational Psychology, Prague, Czech Republic, 1. Sheridan-Leos N. Understanding lateral violence in May 2001. nursing. Clin J Oncol Nurs. 2008;12(3):399-403. 19. Kelly J, Ahern K. Preparing nurses for practice: a 2. McKenna BG, Smith NA, Poole SJ, Coverdale JH. phenomenological study of the new graduate in Horizontal violence: experiences of registered Australia. J Clin Nurs. 2009;18(6):910-918. nurses in their first year of practice. J Adv Nurs. 20. Bartholomew K. Ending Nurse-to-Nurse Hostility: Why 2003;42(1):90-96. Nurses Eat Their Young and Each Other. Marblehead, 3. Griffin M. Teaching cognitive rehearsal as a shield MA: HCPro, Inc.; 2006. for lateral violence: an intervention for newly 21. Woelfle CY, McCaffrey R. Nurse on nurse. Nurs licensed nurses. J Contin Educ Nurs. 2004;35(6):257- Forum. 2007;42(3):123-131. 263. 22. American Association of Critical-Care Nurses. AACN 4. Dellasega CA. Bullying among nurses. Am J Nurs. Standards for Establishing and Sustaining Healthy 2009;109(1):52-58. Work Environments. Aliso Viejo, CA: American As- 5. Stevenson K, Randle J, Grayling I. Inter-group con- sociation of Critical-Care Nurses; 2005. flict in health care: UK students’ experiences of 23. Broome B. Dealing with sharks and bullies in bullying and the need for organisational solutions. the workplace. Association Black Nurs Faculty. Online J Issues Nurs. 2006;11(2):6. 2008;19(1):28-30.

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