Bullying can have extensive effects on nurses at work but action can be taken to dealing with this destructive behaviour
As with many other professions, nursing has its share of bullies who discredit the profession, while other nurses work with dedicated efficiency and good will. Bullying has an impact on the workplace environment and nurses in general; it can cause low morale and in some cases can make nurses seek employment elsewhere or even leave the profession. This article considers recent research into bullying in the workplace, including its prevalence within the profession, causes and identification, as well as different types of bullying and its impact on victims. It also highlights research into combating, preventing and dealing with the problem.
Citation: Lowenstein LF (2013) Bullying in nursing and ways of dealing with it. Nursing Times; 109: 11, 22-25.
Author: Ludwig F Lowenstein is director, Southern England Psychological Services, Allington Manor, Hampshire
- This article has been double-blind peer reviewed
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Workplace bullying is a significant issue confronting the nursing profession, with victims described as being part of an oppressed group. There have been cases where managers have bullied staff or failed to provide support for possible victims (Jackson et al, 2002). However, it is not just senior staff who carry out the bullying; often nurses have reported that both the bullies and victims are the nurses themselves (Hutchinson et al, 2006a).
Needless to say, workplace bullying occurs in numerous other occupations and is a complex phenomenon that can only be understood through looking at social, individual and organisational factors (Johnson, 2009). Johnston et al (2010) pointed out that the issue of workplace violence and bullying is something of which all organisations must be aware as it affects staff and, in the case of nurses, it can also affect patients.
Negative workplace behaviour such as bullying is a worldwide problem (Lindy and Schaefer, 2010). A Portuguese study by Sa and Fleming (2008) described nurses being bullied in the workplace: “[The] individual is persistently treated in an abusive manner over a period of time, with a feeling of not being able to counter-attack or defend him/herself against the abuse.”
Workplace bullying has attracted increased attention over the last 10-20 years due to greater awareness of the consequences for the victims, in this case nurses, as well as those they seek to help -the patients. The issue was highlighted recently by the report into the Mid Staffordshire public inquiry (Francis, 2013).
Prevalence of bullying in nursing
There have been relatively few studies that consider the incidence of workplace bullying in the nursing profession.
A study of clinical nurses in Taiwan by Pai and Lee (2011) reported a high number of incidents involving workplace bullying. Nurses were invited to complete a workplace violence questionnaire, which was designed to assess the frequency and types of workplace violence or bullying, including physical or verbal abuse, bullying or mobbing and sexual harassment. A total of 521 nurses completed the questionnaire; 102 (19.6%) had been subject to physical violence, 268 (51.4%) had experienced verbal abuse, 155 (29.8%) had been victims of bullying/mobbing and 67 (12.9%) reported having experienced sexual harassment. It was noted that working night shifts appeared to increase the likelihood of sexual harassment.
An American study by Vessey et al (2009) of nurses found that bullying was reported by a wide range of staff. Bullying occurred most frequently in medical surgical care (23%), critical care (18%), emergency areas (12%), operating room/post anaesthesia care unit (9%) and obstetric care (7%). Perpetrators included senior nurses (24%), charge nurses (17%), nurse managers (14%) and physicians (8%).
Sa and Fleming (2008) found that one in six nurses (13%) reported being bullied in the past six months.
Identifying the signs of bullying behaviour
Victims of bullying tend to feel intimidated and often experience job dissatisfaction as well as physiological and psychological effects (Cleary et al, 2010). Workplace bullying often takes the form of “incivility and humiliations”, which can lead to shame responses from victims (Felblinger, 2008).
An Australian study by Hutchinson et al (2006a) found “predatory alliances” enabled bullying in the work setting to be hidden. In a later study, they found that those carrying out the bullying tactics were often rewarded by being promoted (Hutchinson et al, 2009). Lewis (2006) also highlighted that managers could be targets of bullying themselves by the people above them.
A Chinese research project studied bullying through the use of questionnaires such as the Chinese Masloch Burnout Inventory, the Negative Acts Questionnaire and the Overall Job Satisfaction and General Health Questionnaire (Li and Zhang, 2010). These inventories were also used to ascertain whether the questionnaire accurately measured the bullying that occurred in the nursing population in a US study (Simons et al, 2011). The study assessed the concurrent validity of the Negative Acts Questionnaire - Revised (22 items) and findings supported the use of a one-dimensional, four-item questionnaire to measure perceived bullying in nursing populations.
Causes and victims of bullying
One of the suggested reasons for bullying is longstanding power struggles arising from conflict of values often caused by organisational conditions and unsympathetic leadership styles (Strandmark and Hallberg, 2007).
Others have noted one of the causes of bullying to be discrimination towards overseas-trained nurses recruited to work in the UK, suggesting that racism can sometimes become entrenched in the nursing workplace (Allan et al, 2009). Hogh et al (2011) found that non-western immigrant health workers had a significantly higher risk of being bullied at work, particularly during their first year of employment and during their trainee period.
The reasons behind bullying can also be political, where it serves the self-interest of the perpetrators and is frequently due to a need for power and competition for promotion (Katrinli et al, 2010). A Canadian study by Laschinger et al (2010) found bullying of new graduate nurses by more experienced older nurses to be common.
A recent study by Huntington et al (2011) linked bullying to increasing pressures of work and organisational factors including a lack of support from management. It also found that workplace bullying can be embedded within informal organisational networks.
Hutchinson (2009) highlighted that bullying is not always identified for what it is because it is associated with a whole organisation. Organisational characteristics influence both the likelihood of bullying occurring as well as whether this behaviour is challenged (Hutchinson et al, 2010a). Nurses frequently find it difficult to complain about the effects of bullying. Whistleblowing can sometimes be viewed as a revenge procedure (Jackson et al, 2010), so organisations can be unaware that the bullying is even happening (Johnston et al, 2010).
Types of bullying
Racism and bullying of immigrant nurses, as documented by Allan et al (2009), suggests racism is entrenched in the nurses’ workplace due to an abuse of power. This can result in psychological distress and be costly to the organisation due to low morale of the nurses being bullied (Cleary et al, 2010).
Gunnarsdottir et al (2006) carried out a comparative study of the bullying of female nurses, primary school teachers and flight attendants. Repeated sexual harassment at work was more common among flight attendants, with 31% of respondents from this group reporting they had experienced sexual harassment at work, compared with 4% of nurse respondents.
Hutchinson et al (2006b) noted that those who perpetrate bullying behaviour were often found in informal organisational alliances, which gave them opportunity to assert some control over teams and to enforce rules through ritual indoctrination, often destroying the self-confidence of those targeted and forcing them either to comply to survive or to resign their position. This form of bullying can also take the form of nurses being asked to do tasks below their level of competence and having areas of responsibility removed or replaced with more trivial or unpleasant tasks, something which frequently happens alongside unmanageable workload levels (Sa and Fleming, 2008).
Bullying can often take the form of cyber-bullying rather than face-to-face. This behaviour should be detected, treated and steps taken to prevent it happening within organisations (Smoyak, 2011).
The impact of bullying
Bullying has both a physiological and psychological effect on victims as well as a negative impact on organisations and patient care (Broome and Williams-Evans, 2011). Nurses who work in a culture of bullying are likely to experience job dissatisfaction, spend more time on leave, have decreased productivity and lower morale (Cleary et al, 2010). This threatens nurses’ wellbeing (Cleary et al, 2010; Felblinger, 2008) and frequently results in them being unable to provide high-quality care (Huntington et al, 2011).
Sheridan-Leos (2008) referred to bullying in nursing as “lateral violence” or “an act of aggression that is perpetrated by one nurse against another”. He felt that lateral violence caused a downward spiral that was costly to individual nurses, causing job dissatisfaction and psychological distress.
This finding is backed up by Hutchinson et al (2006b), who found that bullying destroyed the self-confidence and self-image of those targeted and forced them eventually to resign their position or to reluctantly accept what was happening around them. In a later study, Hutchinson et al (2010b) found that bullying of nurses leads to erosion of professional competence as well as increased sickness absence and employee attrition (Hutchinson et al, 2010b; Johnson, 2009). Li and Zhang (2010) also found that workplace bullying led to burnout, job dissatisfaction and health risks. It was shown to reduce self-confidence and decreasing work productivity by a Canadian study (Mackintosh et al, 2010a). A later study by the same authors had similar results and also highlighted mental health consequences (Mackintosh et al, 2010b).
The obvious detrimental effects bullying has on nurses make it essential that early intervention takes place and that staff recognise what is happening and prevent further bullying (Schoonbeek and Henderson, 2011). The worst outcomes of bullying are victims being subjected to annoyance, exclusion, belittlement and isolation, deprived of resources, and prevented from claiming their rights (Yildirim, 2009).
Combating bullying of nurses in the workplace
A number of steps can be taken to support a healthy workplace and thereby prevent bullying. The literature suggests several ways to tackle bullying within nursing including providing education, developing codes of acceptable conduct and introducing a zero tolerance policy (Broome and Williams-Evans, 2011). Leaders and managers must use a harmonious approach and work collaboratively to prevent any form of intimidation or bullying (Cleary et al, 2009).
It has been noted that nurses with a personal system of resilience are better able to counteract bullying behaviour (Jackson et al, 2007). To make them more resilient, excessive workloads and a lack of autonomy should be prevented.
Whistleblowing is often seen as a negative act fuelled mainly by revenge and sedition; however, nurses should have the opportunity to raise concerns about patients’ care or organisational wrongdoing without fear of accusations (Jackson et al, 2010). It is important to consider confronting the causes of bullying as well as the actual acts (Mackintosh et al, 2010b).
Those in higher ranks in the nursing profession should be aware of signs that could indicate a person is being bullied, such as anxiety and depression or expressing a wish to leave the profession (Quine, 2001). Nurses who feel they are bullied should be encouraged to speak to colleagues and their superiors in the organisation rather than relying on friends and family; if these concerns are not dealt with sensitively, the victims may end up leaving the profession (Vessey et al, 2009).
Allegations of bullying should always be investigated and the organisation itself should take responsibility. To assist in making this a reality, policies must be in place to deal with investigations into bullying and “zero tolerance” of such behaviour when it has been proven to exist. Whistleblowing should be encouraged rather than discouraged and victims of bullying must have opportunity to voice their feelings to their superiors. This could be made easier with the use of suggestion/ complaint boxes.
Nurses at all levels should be aware they are expected to use empathy with their colleagues as part of an anti-bullying policy that everyone must be familiar with. The workplace should be seen as a place not only of physical safety but one without the emotional stress caused by bullying; every member of the team should be treated with courtesy and respect.
Anyone making a complaint should feel confident their concerns will be escalated as necessary and that solutions will be found. This means identifying and confronting the culprits of bullying and, after a fair hearing, disciplining them, or even dismissing them if this is warranted. Victims and perpetrators should both be offered counselling.
Finally, Johnson (2009) recommended more nurse-specific research in to how nurses are treated, including bullying behaviour in the workplace, to generate a greater understanding and allow for solutions to be found.
- Bullying in the workplace is a worldwide phenomenon
- It is not only senior staff who bully; often nurses bully each other
- Bullying can often affect nurses’ ability to provide high-quality care
- Organisational characteristics are critical antecedents of bullying
- Policies to deal with the possibility of bullying in the workplace and “zero tolerance” of this behaviour are needed
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