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Workplace Bullying &

Incivility in Nursing
Lindsay Vasquez & Amy
Wirick

Definition
Bullying
Refers to the repeated,
health-harming mistreatment
of one or more persons by one
or more perpetrators (FinkSamnick, 2015, p. 166)

Incivility
Defined as a low-intensity
deviant behavior with an
ambiguous intent to cause
harm (Hamblin et al., 2015,
p. 2459

What makes healthcare so

The healthcare profession
has one of the highest levels
unique?
of bullying in the workplace. One study reported that
35% of workers have been bullied at their place of
employment (Fink-Samnick, 2015).

Workplace bullying is 16 times more likely to occur in the

health care industry then other sectors (Wright & Khatri,
2015).
The actions of bullying include verbal abuse, job
sabotage, misuse of authority, intimidation and
humiliation, as well as deliberate destroying of
relationships (Fink-Samnick, 2015).

Learner Objectives
To define bullying, lateral violence, and incivility.
To understand the stance of the nursing profession
on bullying and incivility.
To recognize what bullying looks like in the
healthcare field and the causes for this disruptive
behavior.
To understand how bullying affects the nurse, the
organization, and the patient.
To comprehend that bullying and incivility violates
the nursing code of ethics.
To learn ways to combat bullying and how to
implement them in your workplace.

Lateral Violence
A big concern in Nursing
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Lateral violence is an act of aggression that is perpetrated by

one nurse against another.
Perpetrators included senior nurses (24%), charge nurses
(17%), nurse managers (14%), and physicians (8%)
(Lowenstein, 2013).
Lateral violence occurs when people who are both victims of
a situation of dominance turn on each other rather than
confront the system, which may have oppressed them both.
It involves internalizing feelings such as anger and rage, and
manifest those feelings through behavior such as gossip,
jealousy, putdowns, and blaming.
Incivility includes a wide range of behaviors from ignoring a
co-worker, to eye rolling, or yelling (Yoder-Wise, 2014).

New Policy Formation; where does

the nursing profession stand?
This is an issue that cannot simply be ignored. More than 65 million
U.S. workers are affected by bullying in the workplace, equivalent to
the combine population of 15 states (Fink-Samnick, 2015).
The American Nurses Association (ANA) has even taken a stance.
Responding to the needs of nurses, the American Nurses
Association (ANA) created a new timely, informative publication,
Bullying in the Workplace: Reversing a Culture , that sheds new
light on this growing social problem affecting nurses. This
publication helps nurses understand and deal with bullying and its
perpetrators and to counter the culture of bullying in their work
environments (American Nurses Association, 2012).
Incivility and bullying have been so prevalent and detrimental to
patient safety that the Joint Commission issued a sentinel event
alert in 2008 to put an end to these disruptive behaviors among
healthcare workers (Trossman, 2015).

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What Bullying Can Look

Like
Constantly criticizing
Taking credit for others work
Isolating individuals
Accusing someone of errors they did not
make
Withholding important information
Nonverbal intimidation such as staring or
glaring
Discounting individuals thoughts or feelings

The reasons behind bullying can also be political, where it serves the self
in the
public
interest of
perpetrators and is frequently due to a need for power and
competition for promotion (Lowenstein, 2013).

Causes of Bullying
In order to find a solution to bullying, understanding the root of the problem is
essential. There are numerous reasons why individuals are bullied, but we will
expand upon 5 of the main causes.

Hierarchy System
The hierarchy system under which many nurses are working is to blame for much of
the bullying taking place between nurses (Granstra, 2015, p. 252).

Seniority
Senior nurses will exhibit undue authority on newer ones. Sometimes, The senior
nurse will just watch the new nurse fail rather than provide guidance (Granstra, 2015,
p. 252).

Feelings of Insecurity
Nobody wants to be replaced. Even if replacing an employee isnt managements
goal, many experienced nurses feel it is (Granstra, 2015, p. 252)

Patients Protection
Nurses often are protective of their patients, and this strong feeling can have a
detrimental effect on the relationships between nurses.

Differences in Education
Difference in education that nurses receive can lead them to attack one another
(Granstra, 2015, p. 253).
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Root Cause Analysis

Problem
Cause
Root
Cause(s)

Bullying
Bullying &
&
Incivility
Incivility

Hierarchy
Hierarchy
System
System

Seniority
Seniority

History
History of
of
receiving
receiving
orders
orders

Unauthorized
Unauthorized
use
use of
of
seniority
seniority as
as
power
power

Misuse
Misuse of
of
superior
rank
superior rank

Feelings
Feelings of
of
being
being
underappreci
underappreci
ated
ated

Feelings
Feelings of
of
Insecurity
Insecurity

Fears
Fears of
of
replacement
replacement

Patients'
Patients'
Protection
Protection
Fear
Fear of
of
incapable
incapable
care
care for
for 'their'
'their'
patients
patients

Differences
Differences in
in
Education
Education

Lack
Lack of
of
knowledge
knowledge

Lack
Lack of
of
experience
experience

Repercussions of Bullying,
Incivility, & Workplace
Violence

Decreased staff satisfaction

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 (Lowenstein, 2013).

Employee turnover
This is the most financially straining consequence of bullying on the
organization as a whole. It can be very expensive to continuously train new
staff. The average cost to replace a nurse who has left to work at a competing
organization ranges from $22,000 to $64,000 (Granstra, 2015, p. 254).

Staffs mental and physical health

In a study, 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 (Lowenstein, 2013).

Repercussions of Bullying,
Incivility, & Workplace
Violence

Patient satisfaction

Although the individual experiences the brunt of the negative effects of bullying,
others are affected as well. Above all else, the care that the affected nurse
provides often significantly decreases (Granstra, 2015, p. 254).

Quality of Care
When essential information related to patient care is omitted as an act of HV
(healthcare violence), the victimized nurse is in a poor position to care for the
patient and patient safety is compromised. The subsequent cost to patient,
family, and institution from compromised care, as well as the potential legal
action, can be staggering (Becher & Visovsky, 2012).

Absenteeism
Ive had nurses tell me they have checked their
schedules to see if the perpetrator was working their
next shift. If the perpetrator was scheduled to work
with them, the nurses sometimes called in sick
(Trossman, 2015, p. 1).
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Ethical Considerations
To Do No Harm applies to nurses too!
The nurse participates in establishing,
maintaining, and improving health care
environments and conditions of
employment conducive to the provision of
quality health care and consistent with the
values of the profession through individual
and collective action (American Nurses
Association, 2001, p. 20).

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Recommendati
ons
1. Removal of Hierarchy System
The entire infrastructure within healthcare needs
to
be addressed so all healthcare professionals are
equally valued and respected (Granstra, 2015,
p. 254).

2. Education on Bullying
Nurses need education on tools to combat violence.

3. Leaders Setting an Example

Unit leaders have a large influence on when and if
bullying/violence occurs on their unit and if it is
dealt with properly.

4. Workplace Culture and Policies

If stringent policies on bullying are in place and the
consequences are real and followed through, there
will be much less tolerance for this activity.

In Conclusion
Bullying in nurse practice is prevalent.
It is important to remember that every
nurse started as a beginner. Experience
and learning is how we improve.
Bullying affects more than your own
practice, it can affect the health of the
organization.
Patient safety and quality of care must be a
primary concern!
Healthcare organizations need to institute
a zero tolerance policy and back it up.
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References

American Nurses Association. (2012). New ANA Publication Bullying in the

Workplace Addresses a Growing Social, Workplace Problem for Nurses.
Retrieved from
http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/
PressReleases/2012-PR/ANA-Publication-Bullying-in-the-Workplace.pdf
American Nurses Association. (2001). Code of ethics for nurses with
interpretative statements. Silver Sprin, MD: Author.
ANA panel aims to prevent violence, bullying in healthcare facilities.
(2015).Vermont Nurse Connection, 18(3), 9.
Becher, J. & Visovsky, C. (2012). Horizontal Violence in Nursing. MedSurg
Nursing, 21(4), 210-214.
Bujold, D. C. (2015). Nurses eat what?!!! Nevada RNformation. 24(3). 4.
Fink-Samnick, E. (2015). The new age of bullying and violence in health care.
Professional Case Management, 20(4), 165-174. doi:10.1097/NCM.
0000000000000099
Granstra, K. (2015). Nurse Against Nurse: Horizontal Bullying in the Nursing
Profession. Journal of Healthcare Management, 60(4), 249-257.
Hamblin, L. E., Essenmacher, L., Upfal, M. J., Russell, J., Luborsky, M., Ager, J.,
& Arnetz, J. E., (2015). Catalysts of worker-to-worker violence and
incivility in hospitals. Journal of Clinical Nursing, 24(17-18), 2458-2467.
doi10:1111/jocn.12825
Johnson, S. L., (2015). Workplace bullying prevention: a critical discourse
analysis. Journal of Advanced Nursing, 71(10), 2384-2392.
doi:10.1111/jan.12694
Lowenstein, L. (2013). Bullying in nursing and ways of dealing with it. Nursing