BULLYING AND INCIVILITY IN NURSING PRACTICE

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Civility and Workplace Bullying: Resonance of Nightingale’s Persona and Current Best Practices Fidelindo A. Lim, DNP, RN, and Ilya Bernstein, BSN, RN

Fidelindo A. Lim, MA, RN, is Clinical Faculty, College of Nursing, New York University, New York, NY; and Ilya Bernstein, RN, is Research Assistant, College of Nursing, New York University, New York, NY.

Keywords Civility, incivility, nightingale and interprofessional collaboration, workplace bullying

Correspondence Fidelindo A. Lim, MA, RN, Clinical Faculty, College of Nursing, New York University, New York, NY E-mail: [email protected]

Conflict or aggression occurring between and among healthcare workers is undermining attempts to create a culture of safety in the workplace. Healthcare occupations have higher rates of workplace bullying (WPB), and intimidating behavior across healthcare settings has been shown to foster medical errors, increase the cost of care, and contribute to poor patient satisfaction and preventable adverse outcomes. WBP is also par- tially responsible for the high attrition among nurses, a particular concern in the current nursing shortage. Through a narrative that explores Flor- ence Nightingale’s professional persona and experience, this article out- lines various factors that contribute to incivility and WPB, and provides suggestions for curriculum design that may help preempt incivility in tomorrow’s nurses.

In April of 2003, an article in The Washington Post examined the relevance of Florence Nightingale in contemporary nursing. The author cited anecdotes that Nightingale was demanding, manipulative, and overbearing (Nelson, 2003). These unflattering traits—not usually associated with the lady with the lamp—has attracted attention recently in the discus- sion of workplace bullying (WPB) and incivility.

Biographers have documented Nightingale’s intimidating, domineering, and caustic manner along- side her image as an indefatigable ministering angel (Bostridge, 2008; Strachey, 1918). Some of the nurses, particularly those of a lower social class, who worked with Nightingale during the Crimean War, noted how they were treated with disrespect and unkindness by Florence Nightingale (Bostridge, 2008). In our time, her “querulous, demanding and difficult” personality (Bostridge, 2008, p. 331) in dealing with her peers would be regarded as precursors to WPB. Rudeness, disrespect, and general disdain for colleagues are among many examples of incivility in the workplace (Luparell, 2011). It

appears that Nightingale put down nurses even as she tried to elevate the stature of the nursing profession.

Interspersed among practical advice ranging from room air exchange to noise reduction at the bedside, Nightingale’s best-selling book Notes on Nursing is imbued with sharp reproaches for nurses who neglected to do their best. In her punchy and epigram- matic style (Bostridge, 2008), one can feel traces of disdain and sarcasm. For example, she wrote in Notes in Nursing (Nightingale, 1860):

If a nurse declines to do these kinds of things (emp- tying a bedside commode) ‘because it is not her business,’ I should say that nursing was not her calling. (p. 13)

If you look into reports of trials or accidents, and especially of suicides . . . it is almost incredible how often the whole thing turns upon something which has happened because ‘he,’ or still oftener ‘she,’ ‘was not there.’ (p. 23)

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If you wait till your patients tell you, or remind you of these things (keeping noise level down), where is the use of their having a nurse? (p. 27)

But if you cannot get the habit of observation one way or other you had better give up the being a nurse, for it is not your calling, however kind and anxious you may be. (p. 63)

. . . if he (patient) has a bed-sore, it is generally the fault not of the disease, but of the nursing. (p. 6)

To assign blame to Nightingale as the forerunner of today’s incivility issues is to miss the point on why this problem should be dealt with proactively. This article explores the subject of WPB and incivility in nursing and contextualizes Nightingale’s experience with contemporary issues and offers best practices solutions.

Incivility and Its Discontents

It is not uncommon that nurses have to contend with disruptive behavior of patients. But what if the perpetrator is a colleague? Civility or its antithesis has been the subject of discourse in recent years (Luparell, 2011). Overt or covert conflict or aggression, occurring between and among nurses, is known in the literature as horizontal or lateral violence (Stanley, Martin, Michel, Welton, & Nemeth, 2007). Incivility encom- passes rude or disruptive behaviors that often result in psychological and physiological distress for people involved (Clark & Davis Kenaley, 2011). It is not just hurting nurses, it is undermining the culture of safety in the workplace (Joint Commission, 2008).

Intimidating and disruptive behaviors of healthcare workers, such as verbal outbursts and physical threats, as well as passive activities, such as refusing to perform assigned tasks or quietly exhibiting unco- operative attitudes during routine activities, can have a direct impact on patient’s outcomes and safety (Johnson & Rea, 2009; Joint Commission, 2008). The Joint Commission issued a Sentinel Event Alert (SEA) in 2008 to inform healthcare agencies that intimidating behavior across the healthcare settings has been shown to

• Foster medical errors • Contribute to poor patient satisfaction and to

preventable adverse outcomes • Increase the cost of care

• Cause qualified clinicians, administrators and man- agers to seek new positions in more professional environments.

At a time when nursing shortage is acute, a high degree of attrition among nurses due to WPB or inci- vility (Bowles & Candela, 2005; Simons, 2008; Ulrich et al., 2006) is of particular concern. It is estimated that 30% of new nurses left their jobs in the first year and that 57% left by the second year (Bowles & Candela, 2005). Prevalence rates of WPB in nursing range from 21% (Berry, Gillespie, Gates, & Schafer, 2012) to as high as 70% (Vessey, Demarco, Gaffney, & Budin, 2009).

It is interesting to note that of the total of 229 nurses who served during the Crimean War, 40 resigned (17% attrition) and only 17 (including Flor- ence Nightingale) served for the duration of the war. While war will always repel many, the considerable nursing attrition in England during peacetime suggests other factors are at play. Four years after the establishment of The Nightingale Training School in 1860, only 25 of the original 60 were still working (Bostridge, 2008). It is beyond the scope of this article to list all possible combinations of reasons to leave the nursing work- force; however, historical accounts suggest that WPB already played a role in the high attrition rate of nurses 150 years ago, and it still resonates with current trends.

WPB, lateral violence, and incivility are often used interchangeably. A major distinction between defini- tions of WPB and lateral violence is that lateral vio- lence can be used to describe a one-time occurrence, whereas to qualify as WPB, the conflict needs to occur repeatedly, at least weekly over at least a 6-month period (Johnson & Rea, 2009). WPB may be carried out by one or more employees against a target or targets perceived as intentional (Zapf, Einarsen, Hoel, & Vartia, 2003). It is not unheard of to find nurses working in unhealthy environments, being bullied for years.

The Context of Incivility: Review of Literature

Although workplace incivility and bullying can happen in any setting, healthcare occupations have been noted to exhibit higher rates of bullying (Zapf et al., 2003). The majority of healthcare professionals venture into their chosen careers with a strong com- mitment to care for others and one another, with elements of altruism (Joint Commission, 2008).

F. A. Lim and I. Bernstein Civility and Workplace Bullying

Although the number of “difficult” healthcare workers is relatively small, they can significantly corrode the system (Clark & Davis Kenaley, 2011). Dealing with their unprofessional exploits and outbursts require disproportionally large amount of time and effort, and they exact a disproportionate toll on the culture of safety within a group (Luparell, 2011).

Various factors have been identified to contribute to incivility and WBP. These can be classified into individual and systemic factors (Joint Commission, 2008).

Individual (Personality) Factors

• Self-centeredness, immaturity, and/or defensive- ness

• Lack of interpersonal, coping, and/or conflict man- agement skills

Systemic Factors

• Job pressures that include increased productivity demands

• Cost containment requirements and embedded hierarchies

• Fear of or stress from litigation • Differences in the authority, autonomy, empower-

ment, roles and values of workers • Continual flux of daily changes in shifts, rotations,

and interdepartmental support staff.

The inherent stresses of dealing with high stakes situations, particularly in acute care settings, increase the nurse’s vulnerability for outbursts and disruptive behaviors—both as the victim and as the perpetrator (Joint Commission, 2008). High patient ratio might mean low on patience.

Nightingale’s work during the Crimean War was fraught with massive breakdown of communication, lack of government support, severe understaffing, and nonexistent formal education for nurses. This made every patient care interface and interprofessional encounter (between Nightingale the military officials) ripe for uncivil exchange. One can only imagine the tremendous emotional stress Nightingale and her nurses must have experienced laboring in an “unhealthy” working environment. Combined with physical fatigue, the chance for exhibiting unprofes- sional behavior is increased (Joint Commission, 2008). Interestingly, examples of incivility in the Victorian era are shrouded under the veneer of overly polite Victo- rian expressions.

Nightingale’s letters illustrate her introspection of the many uncivil incidents she experienced from the press, politicians, and even from her own family in relation to her career (Bostridge, 2008). Her reflec- tions solidified her advocacy and health reform efforts. Instead of quitting, she doubled her efforts to create lasting reforms in nursing. Debriefing and arbitration of WPB incidents require purposeful reflection to gain meaningful lessons from the experience.

Power struggle and empowerment (Clark & Davis Kenaley, 2011) are two major factors influencing inci- vility and bullying. Often, one of the parties involved is higher in rank, and the victim may be someone who feels less empowered to challenge the perpetrator. Evi- dence suggests that often the target of bullying is a novice nurse (Berry et al., 2012). The power imbal- ance heightens the victim’s difficulty to defend against the negative acts of bullying (Salin, 2003) due to the interdependence between the target and the bully. This creates a quandary because the person expected to mentor and ease transition of novice nurses to becoming experts may also be the bully (Vessey et al., 2009).

In Nightingale’s case, class differences played a role in accusations of incivility on her part. “It should come as no surprise then that Florence’s superintendence of her staff was in large part derived from mistress- servant relationship to which she had become accus- tomed, as a ‘lady’ . . . Her manner towards them at times betrayed its origin in this relationship and was liable to cause offence” (Bostridge, 2008, p. 232). Power and status disparity (Lutgen-Sandvik, Tracy, & Alberts, 2007) resonates in the modern-day’s uncivil transactions between staff and supervisor, senior and junior nurses, and between nurses and physicians.

Civility Research Snapshot: It’s More Than Black and White

While power disparity is difficult to quantify, evidence is emerging that race and ethnicity influence response to WBP. Productivity is more significantly reduced by workplace bullying in White nurses than in non-White nurses (Berry et al., 2012). Authors of this study contend that non-White nurses have developed adaption strategies that White nurses have not as a way of coping with a largely White, oppressive society that allows them to respond differently to WPB (Berry et al., 2012). This study needs to be duplicated given the increasing number of non-White (immigrants and minorities) joining the nursing workforce.

Civility and Workplace Bullying F. A. Lim and I. Bernstein

Resilience competence and cultural factors affect how a nurse responds to WPB. Research is needed to examine how the variables of race, gender, immigra- tion status, career history, support system, and per- ceived social class impact on the dynamics of WPB and incivility. Academia has an important role in creating a future workforce steeped in the highest professional standard of practice and decorum.

Academia and Clinical Setting: A Civil Union

We are often told that a nurse needs only to be devoted and obedient. This definition would do just as well for a porter. It might even do for horse. It would not do for a policeman. (Nightingale, 1860)

Because today’s students are tomorrow’s col- leagues, efforts to address incivility and bullying should include specific aspects of nursing academia and the preparation of new nurses (Luparell, 2011). A student who responded to the Carnegie National Student Nurses’ Association survey said the biggest challenge in nursing education she faced was “being lectured on caring and building trust by instructors who don’t practice what they preach” (Benner, Sutphen, Leonard, & Day, 2010, p. 64). Role-modeling is a key element in creating a future workforce that is socialized into a just culture in dealing with patients, peers, students, and faculty.

One study indicated that students are exposed to a variety of injustices from staff nurses, including being made to feel unwelcome or ignored, being belittled, blamed falsely for events, and being publicly chastised or humiliated (Thomas & Burk, 2009). These types of behaviors earned the profession the unsavory allega- tion that nurses “eat their young.” The American Association of Colleges of Nursing (AACN) stipulates interprofessional communication and collaboration for improving patient outcomes as essential for bacca- laureate nursing education with emphasis on (AACN, 2008):

• interprofessional and intraprofessional communica- tion, collaboration and socialization, with consider- ation of principles related to communication with diverse cultures

• teamwork and concepts of teambuilding and coop- erative learning

• relationship building and group dynamics • conflict management, conflict resolution strategies

and negotiation

These topics are recommended to be incorporated into lectures, seminars, lab, simulation exercises, and clini- cal practicum. Curricular activities must incorporate difficult dialogues dealing with WPB not only between students and faculty, but between faculties. While no specific studies were located that deal with incivility among nursing faculty, anecdotal reports of incivility, particularly during faculty meetings, is not unheard of. One potential source of this rancor is rankism and the hierarchical nature of the academia.

The Nightingale curriculum in “training” nurses emphasized the virtue of service. The apprenticeship system that lasted until 30 years ago is blamed for the collective subservience of nurses. A good nurse does not complain and must endure, so the stereotype goes. But that was then. The education of nurses today must sufficiently address WPB and incivility. Empowerment of students during their formative years is known to promote constructive reciprocal engagement and civil- ity in their future careers (Clark & Davis Kenaley, 2011). In general, nursing curricula are very effective in helping students cultivate a deep sense of profes- sional identity, commitment to the values of the pro- fession, and to act with ethical comportment (Benner et al., 2010).

Interprofessional Collaborative Education: Gateway to Workplace Civility

The Institute of Medicine’s (IOM) Future of Nursing report admonishes that the nursing curricula must promote and engage in interprofessional education and collaboration (IOM, 2010). This is supported by the American Association of Colleges of Nursing, who write in their (2008) handbook on necessary curriculum content that, “Interprofessional communication and collaboration among health professionals is imperative to providing patient-centered care.” Early exposure and engage- ment in interprofessional collaboration and team building will enable the future workforce to apply the virtue of civility in their careers.

Civilizing the Workplace: Fundamentals in Nursing

The principle of respect for persons extends to all individuals with whom the nurse interacts. (Code of Ethics for Nurses; American Nurses Association [ANA], 2008)

F. A. Lim and I. Bernstein Civility and Workplace Bullying

The ANA mandates that nurses exercise civil behav- ior in all their interactions. The provision further stipulates that the nurse’s conduct “precludes any and all prejudicial actions, any forms of harassment or threatening behavior or disregard for the effect of one’s actions on others” (ANA, 2008, p. 149). Aligned with the code of ethics is the American Association of Critical-Care Nurses’ (AACN, 2005) Standards for Establishing and Sustaining Healthy Work Environ- ment consensus report. The AACN standards address relational issues that can impact patient safety and remind nurses of their ethical obligation to uphold workplace civility as one of the core competencies for health professionals.

Although it is commonly accepted that nurses are inherently good-natured people, mastering civility is an acquired skill and therefore must be learned. Regular and consistent practice of professional decorum that starts with a system-wide commitment will enhance staff engagement. The Joint Commission (2008) offers the following suggestions on how to deal with WPB and incivility:

• Educate all team members on appropriate profes- sional behavior as defined by the organization’s code of conduct, with an emphasis on respect.

• Include training in basic business etiquette, particu- larly phone skills and people skills.

• Hold all team members accountable for modeling desirable behaviors, and enforce the code consis- tently and equitably among all staff regardless of seniority or clinical discipline in a positive fashion through reinforcement as well as punishment.

• Develop and implement WPB policies and proce- dures appropriate for the organization.

There is a paucity of substantive research on what constitutes best practice for resolving WPB and incivil- ity (Berry et al., 2012). Based on narratives from Nightingale’s “notes,” blaming the victim is certainly counterproductive and can only exacerbate the pro- blem. She lamented, “Exposed as I am to be misinter- preted and misunderstood, in a field of action in which the work is new, complicated, and distant from many who sit in judgment upon it” (Bostridge, 2008, p. 213). Since each WPB situation is unique, it requires a more nuanced analysis, and therefore, solutions must be individualized. Expert analysis of WPB events must take into consideration the principles of shared gover- nance. Staff feedback and recommendations need to be taken into account if lasting solutions are to be effected.

Conclusion

Reflecting on Nightingale’s fallibility will enable us to contextualize the challenges nurses face in uphold- ing quality and safety in the presence of WPB. Reading Nightingale’s own words strips down the veil of the mythical woman, who, though brilliant and reform- driven, was self-righteous, single-minded, and insistent that tasks be completed to her exact specifications, drawing par- allel between the Lady of the Lamp and the Iron Lady, Margaret Thatcher (Bostridge, 2008). Incivility on the job need not be the social norm. Learning from his- torical references and literature reviews on WPB will enable us not only to mine the pathos of this high- emotion issue, but also increase surveillance and implementation of best practices in order to eliminate it from the workplace.

Bullied nurses are more likely to bully others (Vessey et al., 2009). In seeking remedies to the problem of WPB, nurse leaders need to focus on root cause analysis on why bullying occurs and on ways to halt the vicious cycle (Johnson & Rea, 2009). Practice- based interprofessional collaboration interventions can improve healthcare processes and outcomes in workplace civility (Zwarenstein, Goldman, & Reeves, 2009). With government reimbursement now tied with patient care satisfaction, the impetus to curtail WPB is even greater.

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