Power Dynamics

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Colonel John S. Murr a y, PhD, RN, CPNP, CS, FAAN, is Director of Education, Training & Research, Joint Task Force National Capital Region Medical, Bethesda, MD; and Pre s i d e n t of the Federal Nurses Association.

Note: The views expressed in this art i- cle are those of the author and do not reflect the official policy or position of the United States Air Force, Depart m e n t of Defense, or the U.S. govern m e n t .

John S. Murray

Workplace Bullying in Nursing: A Problem That Can’t Be Ignored

C a rol is a new nurse working on a medical-surgical unit. She is an outstand-

ing nurse — very thorough, attentive to the needs of her patients, and

c o n s i d e red to be a team player by her co-workers. One day, she is asked by

her supervisor to document she had provided care to patients not assigned

to her. Carol declined. In the weeks that followed, Caro l ’s supervisor contin-

ually belittled her in front of other staff and patients, told her she should

have chosen another profession, spoke to her in a condescending manner,

used demeaning language, or just completely ignored her. After months of

continually being bullied, feeling depressed, suffering from loss of sleep and

appetite, and not knowing where to turn for help, Carol resigned her position

and went to work at another hospital.

What Is Workplace Bullying?

Workplace bullying, a serious issue affecting the nursing profession, is defined as any type of repetitive abuse in which the victim of the bullying behavior suffers verbal abuse, threats, humiliating or intimidating behaviors, or behaviors by the perpetrator that interf e re with his or her job perf o rm- ance and are meant to place at risk the health and safety of the victim (Center for American Nurses, 2007; Felblinger, 2008; Longo & Sherman, 2007; Murr a y, 2008a). Often workplace bullying involves abuse or misuse of power and authority within an organization.

Bullying behaviors create feelings of defenselessness in the victim and significantly demoralize his or her right to dignity in the workplace ( D e p a rtment of Labor and Industries, 2006; Longo & Sherman, 2007). This silent epidemic in nursing usually is driven by the perpetrator’s need to be in complete control of an individual, re g a rdless of the pain and suff e r i n g inflicted on the victim. The bully meticulously plans who will be targ e t e d , when the victim will be abused, and how this abusive behavior will be per- petuated. Furt h e rm o re, the bully strategically plans to involve other employ- ees in the bullying behaviors, either voluntarily or by coercing them into the abusive behavior. Ve ry frequently these minions cooperate out of fear of being the next victim (Griffin, 2004; Murr a y, 2008a).

Why Individuals Bully

Nurses may bully others for a number of reasons. The basis most often is solely the need for the bully to be in control of all aspects of the work envi- ronment. The perpetrator of the bullying behavior also may have a person- ality flaw, such as being shortsighted; stubborn to the extreme of psycho- pathic tendencies, such as trying to be repulsively charming; have an exag- gerated sense of self; and lack the ability to be remorseful or feel guilt over the harm inflicted upon others (Anderson, 2002; Felblinger, 2008; Murr a y, 2 0 0 8 a ) .

Bullying behaviors also exist because of a white wall of silence that often p rotects the bully (Murr a y, 2007). In some cases, senior managers ingratiate these behaviors and often protect the bully instead of the victims (Longo & S h e rman, 2007). This unrelenting bullying behavior in the workplace will con- tinue unless health care organizations implement zero-tolerance policies and

Workplace bullying is a seri -

ous problem affecting nursing.

Abusive workplaces result in lack of job satisfaction, poor

retention, and adverse patient outcomes. The purpose of this

a rticle is to present the history

of this problem in nursing and o ffer potential solutions.

274 MEDSURG Nursing—September/October 2009—Vol. 18/No. 5

legislation is passed making work- place abuse illegal (American Association of Critical-Care Nurses [AACN], 2004; Center for American Nurses, 2007; Longo & Sherm a n , 2007; Murr a y, 2008b; Ramos, 2006).

Tell Tale Signs of Wo r k p l a c e B u l l y i n g

The following examples will help nurses determine if they are being bullied (Felblinger, 2008; Longo & Sherman, 2007; Murr a y, 2 0 0 8 a ; ) : • Despite a nurse’s attempt to

l e a rn a new pro c e d u re or com- plete a task, the supervisor is never pleased.

• A nurse is called to unplanned meetings with the superv i s o r (and perhaps others who are witness or participants) where only further degradation oc- c u r s .

• The workplace bully continual- ly undermines and torments a nurse who is trying simply to do his or her job.

• Despite having expertise and a h i s t o ry of excellence in the are a of practice, a nurse is accused of being incompetent.

• No matter how many times a nurse asks for help, and the sen- ior leader tells the nurse action will be taken, the bully contin- ues to interf e re with the nurse’s job perf o rmance.

• The bully screams or yells at the nurse in front of others to make him or her look bad.

• Colleagues are told to stop interacting with a nurse at work and in social settings.

• A nurse constantly feels s t ressed and fearful waiting for additional negative events.

• When a nurse asks an org a n i z a- tional leader for help, he or she is told to “get a tougher skin” or “work out your diff e re n c e s . ”

• Co-workers and senior leaders s h a re the nurse’s concern that the bully is a problem but they take no action to address the c o n c e rn in the workplace.

Consequences of Wo r k p l a c e B u l l y i n g

One of the most profound con- sequences of workplace bullying is the emotional pain suff e red by vic- tims, which also has a secondary

e ffect on co-workers who witness the bullying as well as families who recognize the impact on the bullied loved one. Victims suffer significant a n x i e t y, depression, and feelings of isolation (Murr a y, 2008a). Other consequences include being labeled as a troublemaker; fearing loss of c a reer advancement opport u n i t i e s or job loss, experiencing psychoso- matic symptoms, such as nerv o u s tension, headaches, eating disor- ders, sleep disturbances; and onset of chronic illness. Symptoms of bul- lying can persist over extended peri- ods of time. Furt h e rm o re, victims may develop symptoms of post- traumatic stress disord e r. These wide-ranging consequences can have long-term detrimental eff e c t s on victims, including problems with self-esteem, re c u rrent nightmare s , and depression (Felblinger, 2008).

Impact of Bullying on Health C a re Org a n i z a t i o n s

Bullying in the workplace is a v e ry serious matter that continues to escalate in health care org a n i z a- tions. Although little is written on the topic of workplace bullying as it relates to nursing, literature indi- cates hostility significantly decre a s- es morale as well as job satisfaction ( G reene 2002; Murr a y, 2008a). If abuse is permitted to continue unabated, workplace rights advo- cates expect the financial burden on health care institutions to be u n p recedented. Bullying in the workplace can cost over $4 billion yearly (Murr a y, 2008a). It also has become a major contributor to the i n c reasing rate of work dissatisfac- tion, absences from work, lost pro- d u c t i v i t y, and work-related injuries in health care institutions ( F e l b l i n g e r, 2008; Longo & Sherm a n , 2007; Murr a y, 2008a).

Health care leaders can addre s s workplace bullying by following the F o rces of Magnetism developed by the American Nurses Cre d e n t i a l i n g Center (ANCC, 2008), which de- scribe characteristics that exempli- fy excellence in nursing. For exam- ple, nursing leaders should be well- i n f o rmed risk takers who support s t a ff in providing safe, high-quality patient care. Magnet® leaders are in a key position to advocate for nurs- es who are bullied in the workplace because they realize the potential

impact on patient care delivery. Magnet hospitals also encourage a p a rticipative management style that accepts feedback from nurses at all levels of the organization. In fact, Magnet leaders promote and value nurse input re g a rding concern s . Having these values throughout an o rganization creates the conditions for nurses to re p o rt workplace bul- lying without fear of reprisal or becoming the next victim of the b u l l y. Nurses in Magnet hospitals also have available consultants and re s o u rces to address their concern s related to workplace abuses. These may include experts from pro f e s- sional nursing organizations experi- enced in workplace advocacy or persons from other health care o rganizations in the community who have had success in addre s s i n g workplace bullying. Nurses are a critical influence on org a n i z a t i o n - wide processes and policies, espe- cially as they relate to workplace bullying. Using the Forces of Magnetism can help nurses addre s s this escalating professional work- place issue (ANCC, 2008; Murr a y, 2007; Murr a y, 2008a).

How Nurses Can Pro t e c t Themselves

Nurses can help themselves and others when confronted with bullying in the workplace. Although they may appear to be straightfor- w a rd, these strategies can be diff i- cult to accomplish if nurses do not have support (Longo & Sherm a n , 2007; Murr a y, 2007; Thomas, 2003). • A nurse first must re c o g n i z e

when bullying exists. Fre q u e n t- l y, an individual is told that he or she is not being bullied. H o w e v e r, the victim is aware of being targeted and knows the bully is planning systematically to continue the harassment and i n t e rf e re with the victim’s work.

• A nurse should seek behavioral health services when needed. Workplace bullying is a tre m e n- dously overwhelming experi- e n c e .

• A nurse must be aware of the e ffect of the bullying on person- al health and remain alert to signs and symptoms, such as a n x i e t y, loss of sleep, and eating d i s o rd e r s .

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• A nurse should know his or her rights. State and federal pro f e s- sional organizations might be able to assist a victim of work- place bullying (e.g., American Nurses Association, state nurs- ing associations, the Depart- ment of Justice).

• A nurse must be knowledgeable of workplace policies and pro- c e d u res related to bullying and h a r a s s m e n t .

• A victim should document all incidents of bullying, including date, time, site of occurre n c e , and witnesses.

• A nurse should be pre p a red for the possibility that instead of a d d ressing the problem, senior leaders within the org a n i z a t i o n will not stop the bullying as they protect personal interests.

• Legal assistance may be needed when all other avenues to a d d ress the problem have f a i l e d .

What Nursing Co-Workers Can and Should Do

Nurses also can take a number of steps to look out for each other (Johnson, Martin, Markle-Elder, 2007; Longo & Sherman, 2007; M u rr a y, 2007; Thomas, 2003): • When bullying is occurring, a

nurse should call for help imme- d i a t e l y. Operating room nurses have a method of calling a “Code Pink” to signal co-workers that workplace abuse is occurr i n g . Colleagues who can be re l e a s e d f rom patient care areas go to the location of the code and stare silently at the individual bullying the nurse. This technique gets the bully to re t reat from the chal- lenge or recognize the abusive behavior has been re v e a l e d .

• A nurse should provide support to a co-worker immediately fol- lowing an attack, determ i n i n g what should be done for the vic- t i m .

• The bullying incident should be b rought immediately to the attention of the manager.

• S t a ff should not side with the b u l l y. Doing so may bring tempo- r a ry protection but at a huge ethical cost. An observer should have the integrity to do the right thing and not encourage bully- i n g .

• S t a ff should offer to attend meetings as witnesses when the bullied co-worker is asked to meet with the bully.

• S t a ff should agree to support the bullied co-worker by pro v i d- ing written statements, docu- mentation, and/or sworn testi- mony at legal pro c e e d i n g s .

I m p roving Protections for N u r s e s

Silence unfortunately often al- lows bullying to continue in the workplace (Murr a y, 2007). Per- petrators often have a longstanding h i s t o ry of committing similar abus- es at other institutions in which they were employed. Instead of a p p ropriate and effective action being taken to address the unac- ceptable behaviors, they may get moved from one organization to a n o t h e r. Often it is difficult to term i- nate their employment because they may be educators with tenure and many institutions choose not to take the necessary steps to stop the bullying from taking place. The cul- t u re of academic institutions also must play a critical role in addre s s- ing unethical behaviors of health c a re professionals (Whitehead & Novak, 2003). The nursing Code of E t h i c s mandates that unethical behaviors such as workplace bully- ing be re p o rted through appro p r i- ate channels within health care o rganizations and, if needed, to out- side agencies (e.g. state nurses association, professional nursing o rganizations) with re s p o n s i b i l i t y for safe workplace enviro n m e n t s ( M u rr a y, 2007; Murr a y, 2008a).

To date, most attempts to cur- tail workplace bullying have ad- d ressed only minimally its destru c- tive effect on nursing (Murr a y, 2008a). Legislation is needed to make it a crime for individuals to abuse nurses. The Federal Nurses Association, a constituent member of the American Nurses Association (ANA), has been involved in legisla- tive initiatives that propose critical p rotections for nurses who identify workplace bullying. Legislation such as the Paul Revere Freedom to Wa rn Act would offer protections to nurses who draw attention to w rongdoing in the workplace ( M u rr a y, 2008b).

Nursing Implications

In January 2009, new Joint Commission standards addre s s i n g hostile behavior in the workplace went into effect. These standard s re q u i re health care institutions to have in place codes of conduct, mechanisms to encourage staff to re p o rt disruptive behavior, and a p rocess for disciplining off e n d e r s who exhibit hostile behavior (Joint Commission, 2008). In addition, n u r s i n g ’s Code of Ethics m a n d a t e s re p o rting of unethical behaviors in the workplace (ANA, 2001).

A d d ressing workplace abuse, harassment, and bullying of nurses in the workplace is long overd u e ( M u rr a y, 2008a). Nurses should demand to work in enviro n m e n t s f ree from abuse where a model of ethical behavior is adopted and sup- p o rted (Center for American Nurses, 2007). Health care org a n i z a- tions must adopt and support fully z e ro tolerance policies which re c o g- nize abuse in the workplace will not be tolerated (Murr a y, 2008a; AACN, 2004). Ongoing educational pro- grams are needed to help nurses recognize the signs and symptoms of violence in the work setting as well as actions that will pre v e n t abuse from occurring and stop any abuse that is taking place (Center for American Nurses, 2007). A safe, anonymous mechanism for re p o rt- ing workplace bullying also is criti- cal (Murr a y, 2007). Nurses have a right to practice, learn, teach, and conduct re s e a rch in settings that a re safe and healthy. Stronger laws a re needed to protect whistleblow- ers from retaliation for re p o rt i n g unethical behaviors in the work- place. Nurses must play a leading role in taking political action ( M u rr a y, 2007; Murr a y, 2008b). F i n a l l y, re s e a rch must be conducted for full exploration of factors con- tributing to this escalating pro b l e m (Center for American Nurses, 2007). I n t e rvention re s e a rch aimed at reducing mistreatment is essential, as are studies aimed at testing the e ffectiveness of these interv e n t i o n s (Center for American Nurses, 2007; F e l b l i n g e r, 2008).

C o n c l u s i o n

Health care leaders have a responsibility to employees and the public to provide work enviro n-

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ments that are free from abuse and harassment. When workplace bully- ing has been identified as a pro b- lem, senior leaders must take swift, a p p ropriate action to ensure the abuse stops, the perpetrator is held accountable, and steps are taken to e n s u re bullying does not occur again. Policies and pro c e d u res must be implemented and enforced to e n s u re nurses feel safe to re p o rt incidents of bullying.

In 2006, the ANA adopted prin- ciples related to nursing practice and the promotion of healthy work e n v i ronments for all nurses (ANA, 2006). In its resolution, ANA aff i rm e d all nurses have the right to work in e n v i ronments free of abusive behav- i o r, such as bullying, hostility, abuse of authority, and reprisal for identify- ing abuse in the workplace. Nurses have a responsibility to avoid bully- ing, promptly re p o rt incidents of abuse, and most import a n t l y, pro- mote dignity in the workplace for all health care professionals (ANA, 2008; Murr a y, 2008a).

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