Civility and Nursing Practice: Let’s

Talk About Bullying

Professional Practice NursingMaxine Power-Murrin

March 2015

A rose by any other name....

• Lateral violence

• Horizontal violence

• Bullying

• Intimidation

• Incivility

• Relational aggression

ISMP, 2004

Prevalence

In 2003 the Institute for Safe Medication Practices (ISMP) conducted a

national survey of pharmacists, nurses and physicians regarding intimidation in

the workplace.

In the previous year:

• 88% reported that they had encountered condescending language or voice

intonation

• 87% encountered impatience with questions

• 79% encountered a reluctance or

refusal to answer questions or phone

calls

Prevalence

• In 2009 the American College of Physician Executives conducted a survey

of more than 2,100 physicians and nurses that showed a fundamental lack

of respect between the two groups.

• Nearly 85% indicated that degrading comments and insults were the most

common form of disrespectful behavior followed by:

• Yelling (73%)

• Cursing (49%)

• And inappropriate joking (46%)

Johnson, C. 2009

Prevalence

• A study conducted by Nursing 2011 in the United States and published in

2012 about experiencing or witnessing horizontal violence:

• 955 nurses responded to the survey consisting of 5 questions and was

measured using a 6 point Likert scale

• 82% of respondents reported experiencing or witnessing at least one of the

behaviors weekly or daily

• 34% reported that all five behaviors occur weekly or daily

Dumont et al; 2013.

Prevalence

• Harshly criticizing someone without having heard both sides of the story

• Belittling or making hurtful remarks to or about coworkers in front of others

• Complaining about a coworker to others instead of attempting to resolve a

conflict directly by discussing it with that person

• Raising eyebrows or rolling eyes at another coworker

• Pretending not to notice a coworker struggling with his or her workload

Dumont et al; 2013

Hader, 2008

Prevalence

• In a survey of 1337 U.S. nurses in 2008 more than 50% had experienced or

witnessed at work:

– intimidation, angry outbursts,

– severe and/or inappropriate criticism,

– belligerence, disruptive behaviors,

– bullying or harassment

Stokowski, 2011

Sherman, 2013

Difficult People

• Argue a point over and over

• Choose their own self-interest over what’s best for the team

• Talk rather than listen

• Show disrespect

• Motivation: they wear people down and get what they want

• Some difficult people are bullies

• Difficult people tend to behave the same way

with everyone; bullies target certain people

Tips for Coping with Difficult People

• Don’t try to change the difficult person

• Don’t take it personally

• Set boundaries

• Acknowledge the person’s feelings

• Try empathy

• Hold your ground

• Use fewer words

Sherman, 2013

Task Force on the Prevention of Workplace Bullying

(2001)

Bullying

• Repeated inappropriate behavior, direct or indirect,

• Verbal, physical or otherwise, conducted by one or more persons against

another or others, at the place of work and/or in the course of employment,

• Persistent, systemic and ongoing

• Could reasonably be regarded as undermining the individual’s right to

dignity at work.

Johnson & Rea, 2009

Bullying

• Healthcare occupations have the highest rates of workplace bullying

• Most frequent sources of verbal abuse to nurses:

– other nurses,

– patient’s families,

– physicians

– and then patients (Rowe and Sherlock, 2005)

Dellasega, 2009

Common Behaviors

• Giving the silent treatment

• Spreading rumors.

• Using humiliation and put-downs, usually regarding a

nurse’s skills/ability.

• Excluding a nurse from on-or-off the job socializing.

Common Behaviours

• Teasing another nurse about his or her lack of skill or knowledge.

• Over-checking of work

• Refusing to share information with another nurse or otherwise setting him or

her up to fail.

Dellasega, 2009

What it is....

• The aggressor (BULLY) often is insecure and angry.

• The target (victim) often lives in fear of what might come next.

• Those who witness the aggression (bystanders) are often affected.

Dellasega, 2009

Causes

• Hierarchical workplaces

• Task orientation

• Low morale

• Administrative retreat

• Educational shortcomings

• Oppressed group model

Hurley, 2006; Rainford et al, 2015

Causes

• Stressful healthcare environments

• Productivity demands

• Cost containment

• Embedded hierarchies

• Unfortunate progression of victims who become perpetrators

• Survival strategy for some

• Generational differences

• Mishandling the integration of new nurses

ISMP, 2013

The Victim

• Reduction in self-confidence and self-esteem

• Fear, anxiety, sadness, depression

• Symptoms resembling post traumatic stress disorders

• Low morale-apathy-disconnectedness

• Irritability

• Burnout

• Sleep disorders

Hurley, 2006

The Victim

• Impaired interpersonal relationships

• Removal of self from workplace:

– sick leave

– Absenteeism

• Significantly lower job satisfaction, increased job-induced stress, and a

greater intent to leave a position (Quine, 1999)

Quine, 1999

Consequences

• Compromised patient safety

• Disillusionment with nursing-intention to leave the profession

• Victim can be viewed as the problem

McKenna et al, 2001

Bystanders

• May feel ashamed or guilty because they have failed to intervene.

• Fear they will be the next target

WorkCover NSW, 2008

Why is Bullying Underreported?

• The behavior is not recognized as bullying

• Being unfamiliar with the reporting procedure

• Fear of retribution

• The belief that nothing will change

• Concern that they will be labeled a complainer

Step 2: Realize the Cost

• Negativity leads to a sense of isolation and destroys teamwork

• “Every man for himself rather than we’re all in this together” mentality

• Poor teamwork and communication can cause trouble for patients

• Low satisfaction and morale lead to turnover which triggers other negative

outcomes

Step 3: Take Action!

• Speak up

• Confront the offender

• Make sure its not you!!

• Arm yourself

• Create shared values

• Enlist management’s support

• Be patient and persistent. Culture change can occur, but it happens slowly

Response Strategies for the Victim

• Create a log of all incidents including bystander names

• Confront the bully with the appropriate evidence and support

• Involve manager early on

• Become familiar with workplace bullying policies

• The danger-effect ratio must be high to stop bullying

Johnson et al, 2010

Unit Response Strategies

Decrease negativity, gossip and a culture of blame by maintaining zero

tolerance for any communication that is unhealthy

Increase climate of safety and healthy communication by role modeling and

utilizing opportunities to teach interpersonal and confrontation skills

MAKE SURE IT’S NOT YOU!!!!!!

WorkCover 2008

Organizational Strategies

• Develop policies

• Create awareness

• Identify risk factors

• Inform, instruct, and train

• Control risks

• Encourage safe reporting to bodies with the power to act

Eastern Heath Strategies

Code of Ethics for RN’s

• Ethical nursing practice involves core ethical responsibilities that nurses are

expected to uphold.

• Nurse are accountable for those ethical responsibilities in their professional

relationships with individuals, families, groups, populations, communities

and colleagues (Code of Ethics, 2008) .

CNA, 2008

References

• Canadian Nurses Association. (2008). Code of Ethics for Registered Nurses.

• Dellasega, C. (2009). Bullying Among Nurses. American Journal of Nursing. 109(1), 52-58.

• Dumont, Cheryl., Meisinger, Sandy., Whitacre, Mary Jo and Corbin, Gloria. (2013). Horizontal Violence Survey

Report. Nursing 2013, 42(1), 44-49.

• Hader, R. (2008). Workplace Violence Survey 2008. Unsettling findings. Employees safety isn’t the norm in our

healthcare settings. Nursing Management, 39, 13-19.

• Hurley, Janice E. (2006). Nurse-to-Nurse Horizontal Violence. Retrieved from http://www.nsna.org on January 29,

2011.

• Institute for Safe Medication Practices. (July, 2013). Disrespectful behavior in healthcare…Have we made any

progress in the last decade? Medication Safety Alert! 11(7).

• Institute for Safe Medication Practices. (2004). Intimidation: practitioners speak up about this unresolved problem-

part 1. Medication Safety Alert! 9(5).

References

• Johnson, C. (2009). Bad blood: doctor-nurse behavior problems impact patient care. Physician Executive, 35(6):

6-12.

• Johnson, M.,Phylavanh, P., & Jackson, B. (2010). The Bullying Aspect of Workplace Violence in Nursing. JONA’s

Healthcare Law, Ethics, and Regulation, 12(2).

• Johnson, S.L., & Rea, R.E. (2009). Workplace bullying: Concerns for Nurse Leaders. Journal of Nursing

Administration, 39, 84-90.

• Rainford, W, Wood, S. et al (2015). The Disruptive Force of Lateral violence in the Health Care Setting. Journal

for Nurse Practitioners, 11(2), 157-164.

• Sherman, Rose. O. (2013). Dealing with Difficult People. American Nurse Today, 8(7), 1-3.

• Stokowski, Laura A. (2011). The Downward Spiral: Incivility in Nursing. Retrieved from

http://medscape.com/viewarticle/739328_print on February 17, 2014

References