Healthcare professionals find themselves at increased risk of abusive behavior in the workplace. Is your facility doing all it can to discourage workplace bullying?
Lisa Tenney, RN, has been “bitten, kicked, punched, pushed, pinched, shoved, scratched and spat upon” at work.
Sharing her unnerving experience in a 2018 Joint Commission report on physical and verbal violence committed against healthcare workers, Tenney described the intimidating, threatening behavior she’s been subjected to on the job.
“I have been bullied and called very ugly names. I’ve had my life, the life of my unborn child, and of my other family members threatened, requiring security escort to my car.”
Research has shown that bullying is prevalent in the healthcare profession, with one study finding that around 40% of registered nurses have endured the type of treatment that Tenney has experienced.
That same study found a higher incidence of bullying was associated with poorer physical and mental health among nurses, which in turn decreases their quality of life as well as their ability to deliver safe, effective patient care.
What type of behavior can have such an adverse impact? The Joint Commission defines bullying as repeated, health-harming mistreatment of one or more persons by one or more perpetrators and describes bullying as abusive conduct in the form of verbal abuse, threatening, intimidating, or humiliating behaviors, and intentional interference that can prevent work from getting done.
The Joint Commission also recognizes five categories of workplace violence:
- Threat to professional status (public humiliation)
- Threat to personal standing (name calling, insults, teasing)
- Isolation (withholding information)
- Overwork (impossible deadlines)
- Destabilization (failing to give credit where it’s due)
Experts say healthcare workers should be on the lookout for signs that a colleague—or patient—is being bullied, and that health-care providers and hospital administrators must do their part to create a culture that discourages this type of behavior in no uncertain terms.
The link between bullying and adverse outcomes
It should come as no surprise that abusive behavior in the healthcare setting has a negative impact on patient care. Consider the 2018 Medscape report on the side effects of workplace bullying in healthcare that found the intimidating and disruptive behaviors associated with workplace bullying “fuel medical errors and lead to preventable adverse outcomes.”
For example, patients of disruptive physicians experience 14% more complications in the month post-surgery than those patients treated by surgeons with better bedside managers.
In addition, more than 75% of disruptive behaviors led to medical errors, with 30% contributing to patient deaths.
The same study examined the effect that workplace bullying has on each element of the Triple Aim—improving health, the patient experience and reducing cost. The report found that bullying behaviors negate quality performance “at every turn,” with the incidence of workforce trauma specific to bullying taking a hefty toll. For example:
- 20% of targets meet the criteria for post-traumatic stress disorder.
- Suicidal ideation related to workplace bullying has been recorded at greater than 30%.
- Staff subjected to workplace bullying are twice as likely to commit suicide.
For additional info, check out our free resource guide, Awareness 2020: Recognizing and Stopping Workplace Violence.
Sources and symptoms of bullying
Healthcare workers frequently find themselves at increased risk for workplace violence or bullying.
There are several theories as to why bullying is prevalent in the healthcare setting, says Terri Townsend, MA, RN, CCRN-CMC, a unit-based educator, cardiovascular and outpatient services at Community Hospital Anderson in Anderson, Ind.
“One is oppressed group behavior,” says Townsend. “Hospital hierarchies tend to be set up as line-authority structures, with nursing staff on the lower end.”
This structure tends to contribute to the individual’s lack of control over his or her own situation, says Townsend, and members of the group begin to act out against each other as a way of feeling like they are in control.
“‘Weaker’ members of the group tend to become victims. In addition, nurses have traditionally been in subordinate positions, whether with physicians or hospital administration. Bully nurses learn early on which staff members will be victims and which ones should be left alone.
“Another theory relates to nurses who may have been bullies in childhood or adolescence, and never outgrow the mindset and behaviors,” she continues. “Bullying behaviors are learned behaviors. Once a bully learns how to get what he or she wants through bullying, the behaviors continue and contribute to the toxic work environment.”
These behaviors can manifest themselves in various ways, such as eye rolling, sarcasm, yelling or excluding behaviors, says Kay Clevenger, MSN, RN, a clinical educator in the intensive care and acuity adaptable units at Indiana University Health West Hospital. In some cases, the bully might be an experienced professional with strong clinical skills who does not “identify themselves as a bully,” says Clevenger.
“They believe they are helping the newer nurse develop high standards. Once or if the newer nurse has the courage to stand up to the bully, the bullying may cease,” she says, noting that the employee or patient being bullied must document specific occurrences of this behavior, and talk to a manager about it.
“The targeted person also needs to be supported, via employee assistance programs, chaplains and, above all, their leaders. If the support and efforts needed to help the targeted nurse aren’t there, it might result in the nurse leaving the unit, the hospital and, sometimes, the profession.”
Bullying victims tend to internalize and suppress the symptoms of bullying as long as possible, says Townsend. But there are symptoms that colleagues can identify.
“Outward signs can include avoiding the bully by taking assignments as far away as possible, becoming anxious when the bully enters a room or nurses’ station, refusing to ask the bully for help, even if that is the only person available, and withdrawing socially from other staff members,” says Townsend. “Increased absences can also be a sign of being bullied, as are physical maladies such as headaches or an upset stomach.”
Encouraging a culture of safety
Ideally, bullying will never take place in your facility. Your healthcare system should take pains to create a culture that actively discourages bullying, but also must be prepared to react accordingly when abusive conduct does come to light.
(The American Association of Critical-Care Nurses’ Healthy Work Environment Standards provide steps that healthcare staff members and organizational leadership can take to create the type of healthy culture that dissuades bullying.)
“Bullying needs to be looked at from the perspective of preventing it from happening in the first place,” says Tim McDonald, MD, JD, a physician and chief patient safety and risk officer at RLDatix.
Through the hiring and credentialing processes, there are ways to identify those with a predilection for bullying types of behaviors, says McDonald.
“Other proactive measures include hospital and healthcare system leadership explicitly going over policies in orientation and when onboarding new hires, as well as periodic reminders about the policies for all workers. ‘Here are our rules, we do have policies and we will hold you accountable when you cross that boundary.’”
In the event that bullying does occur, the organization must take steps to create a work environment in which employees feel psychologically safe to report such behavior, adds McDonald.
“Nurses and other healthcare workers need to feel comfortable and anonymous without fear of retaliation, and it’s incumbent on leadership to understand what happens, [and then] move in and hold people accountable.”
It’s worth noting, though, that the offending employee receive empathy and compassion as well, to help them gain “an understanding of why it made sense for this person to behave like they did at that time,” says McDonald.
“These individuals should be approached with good intentions and an understanding that people want to get better, and that’s what healthcare workers do—help people get better. Approach these people with good data, hold it up like a mirror and most of them will get better.”
Ultimately, leadership and culture it fosters will determine how successful an organization is at addressing workplace bullying, says Gail Gazelle, MD, MCC, a master certified coach for physicians and physician leaders, and an assistant professor at Harvard Medical School.
“As the healthcare environment has become more dysfunctional, leaders are often scrambling to put out fires or crises, and there is an air of franticness and negativity,” says Gazelle.
“Sadly, this is particularly true with the added pressures of the pandemic. If not tended to and [if] highly professional norms [aren’t] upheld, instances of bullying can readily occur.”
To learn more about this topic, enroll in our nursing CE course, Violence in the Workplace: Strategies for Prevention and Intervention.
- Joint Commission, 2018. Accessed September 24, 2020. [https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/senti-nel-event-alert-59-physical-and-verbal-violence-against-health-care-workers/]
- Sauer P, McCoy T. Nurse Bullying: Impact on Nurses’ Health. West J Nurs Res. 2017. Accessed September 28, 2020. [https://pubmed.ncbi.nlm.nih.gov/27920345/]
- The Joint Commission, 2016. Accessed September 28, 2020. [https://www.joint-commission.org/-/media/tjc/documents/newsletters/quick_safety_issue_24_june_2016pdf.pdf]
- Occupational Safety and Health Administration, 2015. Accessed September 28, 2020. [https://www.osha.gov/Publications/OSHA3826.pdf]
- American Association of Critical-Care Nurses, 2016. Accessed September 30, 2020. [https://www.aacn.org/nursing-excellence/healthy-work-environments]
- MedLearn Media Inc., 2018. Accessed September 29, 2020. [https://www.icd10monitor.com/the-side-effects-of-workplace-bullying-in-healthcare]