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Bullying: A Hidden Threat

To Patient Safety Continuing Nursing


Joy Longo
Debra Hain

Case Study: Liz’s Story Copyright 2014 American Nephrology Nurses’ Association
iz, an experienced nurse work-

L ing in hemodialysis, is filling in

for the regularly scheduled charge
nurse at an incenter dialysis facil-
ity. She is found sitting at the desk dur-
ing the patient change of shift while
Longo, J., & Hain, D. (2014). Bullying: A hidden threat to patient safety. Nephrology Nursing
Journal, 41(2), 193-199.

Patient safety is a crucial element for quality care in hemodialysis facilities. When eval-
uating possible threats to safety, an important factor to consider is the behavior of the
healthcare staff. Inappropriate behaviors, such as bullying, have been associated with
the patient care technicians are caring poor clinical outcomes. In addressing inappropriate behaviors, it is necessary to consid-
for people receiving dialysis treat- er the role of the work environment. Healthy work environment initiatives provide a pos-
ments. All of sudden, Liz begins sible strategy to prevent and/or address the behaviors.
speaking very loudly requesting her
paper work. She eventually finds the Key Words: Bullying, patient safety, hemodialysis.
papers on top of a machine and yells,
“Who took my papers? I needed Goal
these.” Though nobody appears to be The purpose of this article is to provide an overview of bullying and methods of control-
paying attention to Liz, you can hear ling these behaviors.
quiet whispers. One technician states,
“I try not to schedule myself when I
1. Define a healthy work environment.
know she will be in charge; she always
2. Discuss specific behaviors that are considered “bullying” behavior.
treats us like we don’t know what we
3. Describe how managers, staff nurses, and patients can build the skills necessary to
are doing.” Liz often yells and makes
deal with bullying behaviors.
inappropriate comments about staff in
front of patients. Staff members avoid
her so they do not become victims of
her rants. Though patient care does adequate staff. Recently, this has been safety. To accomplish this goal, a cul-
not appear to be interrupted, there is reflected in patient satisfaction scores tural change needs to occur in which
palpable tension when Liz is working, for the facility. blame is not assigned, but rather,
and several staff quit soon after being potential latent system issues that
hired. Retention is an issue that leads could contribute to error are exam-
the manager to often scramble to find
Introduction ined. A safety culture is one defined by
Patient safety is a priority in health “the beliefs, attitudes, and values of an
care and the responsibility of all organization’s employees regarding
healthcare workers (Institute of Medi- the pursuit of safety” (The Joint
Joy Longo, PhD, RN, is an Associate Professor,
cine [IOM], 2004). The IOM’s land- Commission, 2009) and can influence
Florida Atlantic University, Christine E. Lynn mark report To Err is Human (2000) safety behaviors as well as patient and
College of Nursing, Boca Raton, FL, and can be called attention to the high incidence worker outcomes (Flin, Burns, Mearns,
contacted at jlongo@fau.edu of medical errors and challenged Yule, & Robertson, 2006). One area
healthcare organizations to actively often overlooked as an influence on
Debra Hain, PhD, APRN, ANP-BC, GNP-
BC, is an Assistant Professor, Florida Atlantic reduce errors and improve patient safety is the work environment (Porto
University, Christine E Lynn College of Nursing,
and a Nurse Practitioner, the Cleveland Clinic
Florida, Department of Nephrology. She is ANNA
Research Committee Chair and President of This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
ANNA’s Flamingo Chapter. Association (ANNA).
Statement of Disclosure: The authors reported American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
no actual or potential conflict of interest in rela- education by the American Nurses Credentialing Center Commission on Accreditation.
tion to this continuing nursing education activity. ANNA is a provider approved by the California Board of Registered Nursing, provider number
Note: Additional statements of disclosure and
CEP 00910.
instructions for CNE evaluation can be found on This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
page 200. ing nursing education requirements for certification and recertification.

Nephrology Nursing Journal March-April 2014 Vol. 41, No. 2 193

Bullying: A Hidden Threat to Patient Safety

& Lauve, 2006). A high-quality work Bullying in Health Care worker, including physician, manag-
environment is essential for safety er, charge nurse, or staff members.
(Lowe, 2008). Factors such as staffing In the literature, several terms Though physician behaviors have
and work design can contribute to have been used to identify inappro- been scrutinized (Rosenstein &
how care is delivered (IOM, 2004). priate work behaviors. These terms O’Daniel, 2008), other healthcare
Though efforts have been put into include incivility, bullying, horizontal workers, including nurses, are a con-
training and the redesigning of clinical violence, and mobbing. Though the cern. In one study, 77% of workers
processes, errors still occur, and con- terms are often used interchangeably, reported witnessing inappropriate
sideration must also be given to there are some subtle differences in behaviors in physicians, and 65%
human interactions, an important but meaning. The word incivility can be identified the same behaviors in nurs-
often ignored source of error (Porto & used as a general term to describe es (Rosenstein & O’Daniel, 2008). In
Lauve, 2006). behaviors that disregard the expected another study, nurses were recog-
A healthy work environment is norms in the workplace (Andersson & nized as displaying inappropriate
defined as one that is safe, healing, Pearson, 1999), and is often used in behaviors more frequently than
humane, and respectful of all persons the study of behaviors among faculty physicians (51.9% vs. 49%) (Hader,
and fosters the initiative needed for and students in an academic setting 2008). The incidence of bullying
delivery of quality (American Asso- (Altmiller, 2012; Clark, Olender, according to nursing positions varies,
ciation of Critical Care Nurses Kenski, & Cardoni, 2013; Robertson, with some studies reporting the
[AACN], 2005). A potential threat to 2012). Bullying is defined as “situa- behaviors more frequently from man-
a healthy work environment is the tions where an employee is persist- agers/supervisors ( Johnson & Rea,
behavior of healthcare workers; ently picked on or humiliated by 2000) and some from staff nurses
aggression and other inappropriate leaders or fellow co-workers” (Einarsen, (Vessey et al., 2009). Nurses report
behaviors contribute to the likelihood Raknes, & Matthiese, 1994, p. 382). that aggression from colleagues is
of making an error, delays in care, Mobbing is a term used in Scandinavian more stressful than aggression from
conflict, and stress for healthcare countries (Einarsen et al., 1994) and others, such as physicians and
workers, and become the root cause often refers to situations in which a patients (Farrell, 1999). Unlicensed
for adverse events and near misses group of workers harass one person assistive personnel have also been
(AACN, 2005; Farrell, Bobrowski, & (Leymann, 1990). When behaviors implicated as perpetrators (Dumont,
Bobrowski, 2006; Jirapaet, Jirapaet, & are displayed among workers in the Meisinger, Whitacre, & Corbin, 2012).
Sopajaree, 2006; Rosenstein & same rank, such as staff nurses, rather In areas where there are several clas-
O’Daniel, 2008; Veltman, 2007). In than across power gradients, it is sifications of employees, such as in
2008, The Joint Commission issued a referred to as horizontal or lateral vio- dialysis centers, it cannot be assumed
sentinel event alert concerning lence (Vessey, Demarco, Gaffney, & that the employee with a higher rank-
behaviors of healthcare workers that Budin, 2009). ing will be the aggressor; any worker
were recognized as undermining a Behaviors can constitute emotion- can be a perpetrator of bullying. An
culture of safety. This brought to the al, verbal, or physical acts, including experienced technician may demon-
forefront an issue that has long exist- intimidation, talking behind some- strate these behaviors towards a nurse
ed in health care but was often one’s back, belittling or criticizing a or supervisor, so everyone must be
ignored or accepted as part of the cul- colleague in front of others, unjustified diligent in their awareness of potential
ture. By linking the behaviors to safe- blame, being treated differently than behavior issues.
ty, the urgency of the problem is rec- others, exclusion, social isolation, Several studies have explored
ognized, and this is an important first humiliation, unreasonable demands, healthcare workers’ perceptions of a
step in addressing the behaviors. verbal abuse, and denied opportuni- link between inappropriate behaviors
Whether part of a hospital system ties (Safety & Health Assessment and and negative patient outcomes. In a
or a free-standing hemodialysis cen- Research for Prevention [SHARP] survey of 2,095 healthcare providers,
ter, staff members are vulnerable to Program, 2011; Vessey et al., 2009). intimidation was reported to impact
the same threats to safety that result Behaviors such as these have been patient care by affecting the way med-
from inappropriate work behaviors. allowed to exist in health care due to ication orders are clarified (Institute
To attend to this safety concern, it is fear, lack of confidentiality around for Safe Medication Practices [ISMP],
important to understand what consti- reporting, lack of managerial follow- 2004). In a study of 1,509 healthcare
tutes inappropriate behavior in the through on complaints, lack of infor- workers, of the 1,487 who responded
workplace, what contributes to and mation about where to get help, and to a question regarding awareness of
supports the behaviors, and what can the victim’s concern for their job potential adverse events resulting
be done to curtail them. With this (Barnsteiner & Madigan, 2001; from disruptive behaviors, 60% re-
knowledge, the work environment Rosenstein, 2002; Strauss, 2008). ported they were aware of such events
can be enhanced to support a culture Bullying behaviors can be dis- (Rosenstein & O’Daniel, 2005). In a
of safety. played by any category of healthcare subsequent study of 4,530 healthcare

194 Nephrology Nursing Journal March-April 2014 Vol. 41, No. 2

workers, Rosenstein and O’Daniel zational conditions (Strandmark, & and lower depersonalization in nurses
(2008) found that “67% of the respon- Hallberg, 2007). Adult bullies are (Arikan, Köksal, & Gökçe, 2007).
dents felt that there was a linkage seen to be jealous of those with high- These evaluations are also associated
between disruptive behaviors and er qualifications ( Johnson & Rea, with higher levels of perception of
adverse events, 71% felt that there 2009). Evaluation of the work envi- personal success and job satisfaction
was a linkage to medical errors, and ronment needs to include managers’ than those who rate the relationships
27% felt that there was a linkage to examination of their own behaviors as moderate or poor (Arikan et al.,
patient mortality. Eighteen percent of ( Johnson & Rea, 2009). In cultures 2007). A lack of communication bet-
the respondents reported that they where bullying is supported, the man- ween the physician and the nurse can
were aware of a specific adverse event ager may adopt bullying as a man- result in stress for the nurse (Dermody
that occurred because of disruptive agement style (Barber, 2012). & Bennett, 2008), and conflict bet-
behavior, 75% of whom felt that the Managers and charge nurses may use ween nurses and physicians and bet-
adverse event could have been pre- power to intimidate superiors and ween nurses results in feelings of
vented” (pp. 465-466). In a study of may turn a blind eye to the behaviors anger and frustration (Wellard, 1992).
labor and delivery units, 53% of the both around them or instigated by Though there have been reports of
participants reported that inappropri- them (Dumont et al., 2012). poor relationships in dialysis units,
ate behavior contributed to a near Legitimate organizational processes there have also been reports of posi-
miss, and 41.6% stated a specific may be misused to promote bullying, tive relationships (Thomas-Hawkins,
adverse outcome occurred due to an such as change or restructuring, using Denno, Currier, & Wick, 2003).
inappropriate behavior (Veltman, performance reviews as a way to harm When asked about areas that can be
2007). In addition to threatening the others, and promoting themselves to improved in dialysis practice, staff
quality of care delivery to patients, enhance their private power and relations have been identified as an
inappropriate work behaviors can career opportunities (Hutchinson, area of concern (Perumal & Sehgal,
also impact the worker and the organ- Wilkes, Jackson, & Vickers, 2010). 2003).
ization. Victims report digestive prob- When inappropriate behaviors A work issue integral to dialysis
lems, insomnia, long-term sickness, occur between colleagues on the centers is staff recognition. Nurses
and greater psychological distress same level, behaviors are contributed working in dialysis have reported the
than those not bullied (Ortega, to a specific power struggle called desire to be heard and recognized for
Christensen, Hogh, Rugulies, & Borg, oppressed group behavior (Roberts, their contributions to patient care
2011; Rodwell, & Demir, 2012). 1983). In these circumstances, op- (Gardner & Walton, 2011). These nur-
Bullying has been shown to be nega- pressed individuals feel devalued, and ses reported that their opinions are
tively correlated with job satisfaction as a result, have low self-esteem. They not valued and said they would like to
and productivity, and positively cor- become angry and frustrated. They have a more active role in team-build-
related with intent to leave, all of want to act out these frustrations, but ing and creating solutions (Gardner &
which can have fiscal implications for cannot do so towards the oppressor, Walton, 2011). Nurses working in
an organization (Berry, Gillespie, Gates, so they act out towards others. The dialysis also report wanting the
& Schafer, 2012; Hoel & Giga, 2006; oppression has been said to result opportunity to participate in policy
Johnson & Rea, 2009). from the position of nurses in the decisions or internal governance of
hierarchy of the hospital and female units (Thomas-Hawkins et al., 2003).
Origins of Bullying gender (Farrell, 2001). This can be In one study, only half of the nurses
In order to fully understand bul- extended to include anything that surveyed stated they had control over
lying and other inappropriate behav- may hold back the ability to practice their practice or were supported in
iors, it is imperative to explore factors to the full extent of a position, result- introducing new or innovative ideas
in the work environment that may ing in feeling powerless to accomplish (Thomas-Hawkins et al., 2003). Many
support and contribute to the perpet- what needs to be done. Bullying then conflicts that arise stem from the lack
uation of the behaviors. The main fac- becomes the means of expression of of power over practice (Wellard,
tor associated with bullying is power, perceived power. 1992). When nurses feel empowered,
real or perceived. Bullying specifical- there is less report of burnout, which
ly is concerned with a power differen- ultimately influences the retention of
Work Behaviors in Dialysis Centers
tial (Lewis, 2006). Through the devel- nurses (O’Brien, 2011). It has been
opment of subgroups and cliques, The impact of work relationships reported that one in three nurses
bullying is hidden (Lewis, 2006). It is has been studied in dialysis environ- working in dialysis centers experience
also possible that the manager can use ments. It has been found that when burnout, and nurses report higher lev-
bullying as a way to accomplish work nurse-physician relationships and els of burnout than physicians (Klersey
(Lewis, 2006). The power struggle can views of co-workers and administra- et al, 2007; O’Brien, 2011). The higher
originate from conflicting values at tion are positive, there is lower job level of burnout in nurses may be
the workplace based on poor organi- stress, lower emotional exhaustion, reflective of the closer intensity and

Nephrology Nursing Journal March-April 2014 Vol. 41, No. 2 195

Bullying: A Hidden Threat to Patient Safety

duration of the relationship with peo- of the change but also the rationale nary collaboration. It is essential that
ple with chronic disease receiving for the change. Without this crucial nurses support each other in their
hemodialysis three times a week piece of information, a misunder- work. Without this solidarity, nurses
(Klersey et al., 2007). Regardless of standing of the intent may occur, and will not be well represented when col-
the healthcare setting, structures and it may appear as if the staff member is laborating with other disciplines and
strategies that support empowerment being forced to carry out a task that staff. This support extends to instan-
of the nurses need to be in place. may add unwarranted stress. This can ces when bullying occurs and the
be interpreted as bullying when in importance of assisting the victim
fact there is a legitimate reason for the even if it is just by listening to his or
Healthy Work Environment
change. her story. Rallying around a victim in
To Counteract Behaviors
When bullying occurs, there solidarity demonstrates a united front
In order to address inappropriate should be appropriate dialogue bet- against the bully and is a means of
work behaviors, it is necessary to look ween the parties involved. Bullying is taking power away, thus deflating the
for solutions within the work environ- likely to result in emotional respons- perceived outcomes from the bully-
ment. A healthy work environment is es. In such cases, communication may ing.
one in which quality and safe care is be curtailed, or the bullying may esca-
delivered. Six standards have been late. Conversations regarding disre- Effective Decision-Making
identified as essential for a healthy spect and teamwork have been found Effective decision-making entails
work environment: 1) skilled commu- to be challenging in health care, and valuing nurses’ partnership in making
nication, 2) true collaboration, 3) ef- as a result, may not be undertaken policy, directing and evaluating clini-
fective decision-making, 4) appropri- (Maxfield, Grenny, McMillan, Patterson, cal care, and leading organizational
ate staffing levels, 5) meaningful & Switzler, 2005). Education on how operations (AACN, 2005). In such a
recognition, and 6) authentic leader- to respond to bullying through inter- model, everyone shares accountabili-
ship (AACN, 2005). Each of these ventions, such as cognitive rehearsal ty. In addressing inappropriate work
standards can be evaluated in terms (Griffin, 2004), offer assistance for behaviors, decisions need to be made
of understanding and addressing starting these conversations. regarding reports of bullying and
inappropriate behaviors in healthcare An important step in tackling ways to address it, and it is imperative
environments, such as dialysis cen- inappropriate behaviors such as bul- that all aspects of the situation are
ters. lying is to recognize the behaviors studied. In some instances, serious
(American Nurses Association [ANA], safety breeches are recognized. With-
Skilled Communication 2012) and the potential detrimental out a proper means of communicat-
Skilled communication is founda- effects on both patients and staff. ing such concerns, the concerns are
tional for nurses to exchange informa- Though the idea of bullying is not expressed through yelling or other
tion with other healthcare workers new in health care, it is now being dis- forms of inappropriate behavior,
and to inform patients of their health cussed as a potential source of errors. earning the label of bullying. In the
status and needs. It is recognized that Educating staff on appropriate and initial sentinel event alert issued by
communication is as important as any inappropriate behaviors and having The Joint Commission, the term dis-
clinical skill (AACN, 2005). Commu- organizational policies in place to ruptive behavior was used to describe
nication is especially important when address behaviors are ways of com- the inappropriate work behaviors. It
examining workplace behaviors at all municating acknowledgement that was then recognized that at times dis-
levels. Nurses must have an outlet for the behaviors are being taken serious- ruption is needed to bring to light
voicing ideas and concerns related to ly (The Joint Commission, 2008). issues that could be impeding care, so
patient care and delivery. If nurses This puts staff on alert that the behav- the term was changed to “behavior or
feel they are being ignored or their iors will not be tolerated. Leaders behaviors that threaten a culture of
concerns are not being taken serious- need to communicate their expecta- safety” (The Joint Commission, 2011).
ly, it could prevent them from con- tions to all employees. In light of this, each report of bullying
tributing to future discussions, and needs to be properly investigated so
crucial input will be missed. If safety True Collaboration appropriate decisions are made as to
issues are being raised, it is imperative Health care is provided through how to address the occurrence. This
these are heard and addressed before interdisciplinary means, and each dis- may involve bringing parties together
they threaten patients. cipline has an essential role to fulfill. to investigate circumstances and de-
Communication is also a means It is important that nurses work col- termine appropriate actions. These
of providing nurses with the tools laboratively with other members of can range from work process changes
needed for patient care. When there the healthcare team. A well-function- to mentoring and coaching staff re-
is a change in policy or a new initia- ing team is essential to meet the needs garding behaviors. In some situations,
tive needs to be carried out, the man- of the patients. Interdisciplinary col- the human resources department may
ager needs to inform the staff not only laboration starts with intradiscipla- become involved so that the rights of

196 Nephrology Nursing Journal March-April 2014 Vol. 41, No. 2

all are protected in instances where back, but rather, a sense of empower- about Liz’s behavior, Doris sets up a
termination is warranted. ment. Self-esteem is built rather than meeting with Liz to discuss the staff
anger and frustration. Similar to hos- complaints. When Doris tells Liz how
Appropriate Staffing pitals, empowerment structures are staff feel, Liz is shocked. She had been
Appropriate staffing implies there important in dialysis centers (O’Brien, working at the same center for 20
is an effective match between nurse 2011). Dialysis can be very task-orien- years, and no one has ever approach-
competencies and patient needs tated, so it is important that leaders ed her about her behavior before
(AACN, 2005). Though nurse-staffing support staff in all roles by recogniz- Doris. In fact, she often receives acco-
ratios can be a concern in dialysis ing the need for additional training. lades from her patients and is seen as
centers (Perumal & Sehgel, 2003), ap- a hemodialysis expert. Upon further
propriate staffing can be built upon Authentic Leadership discussion, Doris learns that Liz
the use of support services and the It would be difficult to establish enjoys caring for patients but has
inclusion of technology to increase and maintain a healthy work environ- received little training in terms of
effectiveness of nursing care delivery ment without the support of the lead- management, though she frequently
(AACN, 2005). When there are sev- ers of the organization. Nurse leaders assumes the charge nurse role. Liz
eral categories of staff, it is imperative need to fully engage in the pursuit of states: “When I am in charge, I have
that the role of each is understood healthy work environments through to make sure that everything gets
and each is acknowledged as integral their own authenticity and commit- done properly, and the only way that
to patient care. There is little evidence ment (AACN, 2005). This includes happens is if I show the others who is
of what defines appropriate nurse evaluation of leadership styles to boss. No one knows how to do any-
staffing in dialysis centers (Wolfe, assure that bullying or other inappro- thing unless I tell them how.” Doris
2011). Interestingly, standards for priate tactics are not being used to decides that there is an opportunity
staffing ratios for patient care techni- accomplish work or personal goals. for skill building with Liz and
cians to patients are prevalent in all Authentic leadership to address bully- arranges for her to attend charge
states. In any circumstance, the ing includes setting standards for nurse classes offered by the employer.
staffing should meet the needs of the expected behaviors and fully investi- In addition, Doris begins to meet reg-
patients. gating complaints of bullying from ularly with staff to learn about chal-
others. When the leaders do not fol- lenges they face in the work setting.
Meaningful Recognition low through on complaints, it appears Within a few months, a change is seen
Meaningful recognition brings to as if the behaviors are not being taken in Liz and in the work environment.
light the value each member of the seriously or are being ignored, thus Staff satisfaction and retention im-
team brings to the work of the organ- unwillingly allowing the behaviors to proves. Patients who have been at-
ization (AACN, 2005). According to continue. When nurse managers tending the center for a period of time
the IOM (2010) report, The Future of demonstrate authentic leadership, notice a difference in staff demeanor
Nursing, nurses must practice to their lower levels of bullying are reported and compliment Doris on the positive
full potential to meet their responsi- by newly licensed nurses (Laschinger change they see in the unit.
bilities. To accomplish this, what they & Fida, 2013).
can contribute to patient care through It is essential that leaders in an Conclusion
knowledge and skills must be recog- organization demonstrate uniformity
nized. The dialysis work environment in addressing instances of bullying, Patient safety is an integral com-
has been reported to be somewhat starting with the investigation of alle- ponent of health care. Any possible
supportive in terms of nurses fully gations of bullying through carrying means of interference to the provision
participating in practice and being out the established policies. Through of quality health care needs to be
valued (Gardener, Thomas-Hawkins, the use of skilled communication, the evaluated, and this can include be-
Fogg, & Latham, 2007), but is seen as action plan can be disseminated haviors of the nurses and other
an area for improvement (Flynn, though specific details and may be healthcare providers. A healthy work
Thomas-Hawkins, & Clark, 2009). withheld due to confidentiality issues. environment needs to be created in
Knowledge and skills can be seen as a which nurses are empowered to prac-
source of power, and these provide a Liz’s Story: Through the Lens tice to their full capacity and are
portal through which nurses can con- Of a Healthy Work Environment acknowledged for their contributions.
tribute to patient care. Recognition of With these initiatives, there may be
these contributions encourages nurses Though several staff members fewer power struggles that are
to continue on in their pursuit of the have complained to the unit manager demonstrated through inappropriate
delivery of quality care. In environ- about Liz’s behavior, nothing appears work behaviors, resulting in safer en-
ments where nurses are recognized to be done. The unit manager moves vironments for patients and for nurs-
for their contributions, there is no away, and a new manager, Doris, is es in dialysis centers.
sense of oppression or being held hired. Upon hearing consistent stories

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Bullying: A Hidden Threat to Patient Safety

Einarsen, S., Raknes, B.I., & Matthiesen, place: The effectiveness of manage-
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