Nurs Admin Q

Vol. 43, No. 3, pp. 274–279

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Our Own Worst Enemies

The Nurse Bullying Epidemic
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Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN;

Caroline Zelonka, BS
Nurse bullying is a systemic, pervasive problem that begins well before nursing school and con-
tinues throughout a nurse’s career. A significant percentage of nurses leave their first job due
to the negative behaviors of their coworkers, and bullying is likely to exacerbate the growing
nurse shortage. A bullying culture contributes to a poor nurse work environment, increased
risk to patients, lower Hospital Consumer Assessment of Healthcare Providers and Systems (HC-
AHPS) patient satisfaction scores, and greater nurse turnover, which costs the average hospital
$4 million to $7 million a year. Addressing nurse bullying begins with acknowledging the problem,
raising awareness, mitigating contributing factors, and creating and enforcing a strong antibullying
policy. Nurses and stakeholders also must actively work to change the culture, and understand
that bullying has no place in the nursing profession or anywhere else in health care. Key words:
lateral violence, nurse bullying, nurse shortage, nurses, nursing, workplace bullying

N URSES in the profession call it “eating

our young.” Some consider it ingrained
in the culture, a rite of passage, or an unavoid-
clinical rotations.3 Within the first 6 months,
60% of nurses leave their first job due to the
behavior of their coworkers.2
able fact of a nurse’s life. But no matter how Nurse bullying occurs in almost all care set-
it is explained away, nurse bullying takes a tings and units, from the patient floor to the
heavy toll. “To name a thing is to take its executive suite. In fact, 60% of nurse man-
power away.”1 Bullying is a targeted and de- agers, directors, and executives in one 2018
structive behavior that must be called what it study4 said they experienced bullying in the
is in order to address and eliminate in one of workplace, and 26% considered the bullying
the most caring professions. “severe.”
The nurse bullying phenomenon is well- This article discusses the forms and per-
documented in the clinical and leadership lit- petrators of nurse bullying, and factors that
erature. It starts early and is present from the contribute to it. It also examines why bully-
classroom to the bedside to the boardroom. ing is such a pressing problem for health care
One study showed that over a 6-month pe- organizations, how it can affect their clinical
riod, 78% of students experienced bullying in and financial outcomes, and strategies for ad-
nursing school.2 In another study, over half dressing it.
of nursing students reported seeing or expe-
riencing nurse-on-nurse bullying during their
WHAT DOES NURSE BULLYING LOOK
LIKE?
Author Affiliations: AMN Healthcare, Dallas, Texas
(Dr Edmonson); and Scrubs Magazine, Chatsworth, Also known as horizontal hostility, rela-
California (Ms Zelonka).
tional aggression, and lateral violence, the
The author declares no conflict of interest.
American Nurses Association defines nurse
Correspondence: Caroline Zelonka, BS, Scrubs Mag-
azine, 9800 De Soto Ave, Chatsworth, CA 91311 bullying as “repeated, unwanted harmful ac-
([email protected]). tions intended to humiliate, offend and cause
DOI: 10.1097/NAQ.0000000000000353 distress in the recipient,” calling it “a very
274

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 Our Own Worst Enemies 275

serious issue that threatens patient safety, RN WHO IS DOING THE BULLYING?
safety and the nursing profession as a whole.”5
Bullying can run the gamut from incivility While it is true that some older nurses
and exclusion to physical violence and death pick on their younger colleagues, bullying
threats. It is important to realize the prob- behavior transcends age, gender, and expe-
lem occurs along a continuum that can es- rience level.7 Younger nurses might criticize
calate when not addressed. While there are their elders’ appearance or physical limita-
too many acts of bullying to list here, they tions. Older nurses may take advantage of
can be roughly divided into overt and covert younger colleagues’ lack of experience or un-
behaviors. familiarity with minor elements of the job.
Overt bullying is easier to recognize, and in- Male nurses can bully female nurses, regis-
cludes techniques like extreme micromanag- tered nurses (RNs) mistreat licensed practical
ing, verbal criticism, name-calling, insults, nurses (LPNs), and vice versa. Those in cer-
and direct threats. Covert bullying is in- tain specialties and units have been known
direct and passive-aggressive, and can in- to gang up on nurses in other departments.
clude rumors and gossip, withholding infor- And of course, there is always one-on-one
mation, unfair assignments, low grades or harassment, and bullying for no discernible
undesirable tasks as punishment, and sabo- reason. The most frequent bully of nurses is
tage. Microaggressions—brief and common- other nurses.8 A list of common nurse bully
place indignities denigrating a person’s race, archetypes appears in Table 1.
religion, or membership in another marginal- Bullies often lack self-confidence and may
ized group—are also considered a form of see certain colleagues as threats. Some may
covert bullying. worry about younger nurses usurping their
In the digital world, social media, text mes- place in the hierarchy, and others can feel
saging, online forums, and even video games threatened by their elders’ competence and
have expanded the scope of all bullying. This experience. Often, this is a learned behavior
includes direct harassment as well as indirect from early childhood, or a transmuted behav-
harm. In her seminal book, Ending Nurse-to- ior in victims of bullying, who become bullies
Nurse Hostility, now in its second edition, for self-protection.
author Kathleen Bartholomew, RN, MN, cites Personality traits also play a role. Anxiety,
examples of indirect cyberbullying, where anger, and vengefulness make it more likely
nurses are shown derogatory comments and that someone will become a bully, but these
posts about them in private text threads and traits are not exclusive to nurses. The three
online groups.6 primary roles of bully (perpetrator), victim
Even if the person does not intend the (target), and bystander (witness) must each
comment to be seen, or deletes it moments be examined closely in every situation. In a
later, there is no stopping others from tak- bullying environment, cliques can form, and
ing a screenshot and sending it to the tar- scapegoats and favorites emerge. Some nurses
get, often with good intentions. The ease will become bystanders, some will learn to ig-
and immediacy of digital media—and the fact nore the problem, and some will become bul-
that it extends communication beyond the lies themselves—perpetuating the toxic cy-
workplace—magnifies the impact of negative cle. The ultimate goal is to change the bullies’
behaviors. An offhand remark made in a brief behavior, strengthen and support victims, and
moment of frustration can cause great dam- turn bystanders into upstanders.1
age when it is communicated in a digital Workplace bullying also requires the right
form. In addition, we have learned that so- environment to thrive. The quality of lead-
cial media promotes passive-aggressive and ership, in the unit and in the organization,
anonymous bullying toward individuals and can contribute to a bullying culture. Supervi-
groups. sors and managers who lead by intimidation

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276 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019

Table 1. Common Nurse Bully Archetypesa

The supernurse is often more experienced or specialized than most, and communicates a sense of
superiority through an elitist attitude, condescending manner, and “corrective comments.”
The resentful nurse develops and holds grudges, encourages others to “gang up” on the
transgressor, and tends to create drama that can permeate the work environment.
The PGR nurse uses put-downs, gossip, and rumors (PGR) to bully other nurses, and is often quick
to take offense to a neutral remark.
The backstabbing nurse is “two-faced,” cultivating friendships that they then betray, using
information as a weapon to enhance their power.
The green-with-envy nurse expresses bitterness to those who have what they do not: looks, status,
personality, possessions. Their victims often do not realize they are a target.
The cliquish nurse uses exclusion as a means of aggression, showing favoritism to some while
ignoring others

a Reprinted from American Nurses Association5 and Dellasega.23 Used with permission.

and fear tend to foster the same in their staff. of support for the primary mission of the or-
Nurses in management or middle manage- ganization (patient care), and even exclusion
ment occupy some of the highest-pressure bullying—being intentionally left out of criti-
positions in health care, and this pressure cal decisions.
comes from every direction. In many organiza-
tions, a lack of authority coupled with a high NURSE BULLYING CULTURE AND THE
level of accountability makes the individuals “2030 PROBLEM”
in these positions feel somewhat powerless.
Nurses in management roles often adopt a Bullying is more likely to occur in high-
leadership style modeled on bad bosses in the stress settings with high-stakes outcomes,
past, which tends to intensify under pressure. heavy workloads, and low job autonomy—
When bullying becomes part of the culture at all part and parcel of the nursing profession
an organization, these behaviors tend to per- and health care in general. As if the job were
sist, even as individual nurses come and go. not stressful enough, a concatenation of cir-
While nurse leaders encounter bullying and cumstances is bringing new pressures to the
incivility, their experience does not directly patient care industry.
mirror that of clinical nurses. Exploring the The Baby Boomer generation of adults born
uniqueness of the bullying experience among between 1946 and 1964 is one of the largest
nurse leaders, Edmonson9 found they experi- and unhealthiest populations in US history.
ence moral distress when they know the right By 2030, there will be a 73% increase in the
thing to do, but are prevented from doing it number of Americans older than 65 years.
due to organizational factors. Nurse leaders, Half of them will be affected by chronic dis-
like clinical nurses, have little formal training ease, which accounts for over 80% of hospital
in ethics and are challenged to frame experi- admissions.10
ences like bullying in an ethical framework, At the same time, the current and future
and then to act. Nurse leaders, including ex- nursing shortage is accelerating the 2030
ecutive nurses, also experience bullying from problem. The average age of a registered
those who are perceived as higher in the au- nurse is now 50 years, and the average nurse is
thority gradient, including executives in op- 30 years old when they enter the profession.11
erations and finance, medical staff, and so on. A third of today’s nursing workforce will likely
The bullying nurse leaders’ experience can retire in the next 10 to 15 years. Nursing
take the form of directives that may create school faculty is also on the decline,12 lim-
safety situations for staff and patients, lack iting the number of enrollees schools can

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 Our Own Worst Enemies 277

handle and decreasing the overall quality of This study was the first to explore in detail
their programs.13 A good percentage of nurses what many already suspected: that unhappy
end up dropping out before retirement age— nurses can create dissatisfied patients.
turnover rates range from 8.8% to 37% de- The report goes onto say: “Improving
pending on the state.13 nurses’ work environments . . . may improve
Some of this can be attributed to family the patient experience and quality of care.” A
and child-rearing, as in any female-dominated better nurse work environment has also been
profession. Nursing is not for everyone. It linked to lower risks of death and better out-
is physically and mentally demanding, with comes for patients.15
long hours over weekends and holidays. It has A 2008 study of 511 randomly selected Mas-
been called the most dangerous profession, sachusetts RNs found that bullying impacted
not only from a workplace violence perspec- job satisfaction even more than salary.16 This
tive, but also because of an alarming rate of and other research shows workplace incivility
back injuries due to lack of teamwork, limited is strongly linked to burnout and job dissatis-
resources, and lack of equipment and training. faction. Nurses experiencing this often make
But even nurses who love their jobs, and plans to leave their jobs,16 and when they do,
who are able to handle the physical and men- the cost can be high.
tal demands, can be driven out by a toxic work
environment. Unlike the “silver tsunami” of THE HIGH PRICE OF NURSE BURNOUT
aging Baby Boomer patients, bullying-related
nurse attrition is a complex but highly control- In 2018, the average cost of turnover for a
lable factor. Addressing the problem requires bedside RN ranged from $38 000 to $61 100,
total commitment at every point in the health with the average hospital losing $4.4 million
care ecosystem, from the individual level to to $7 million.17 Each percentage change in
the organizational, including policy and advo- RN turnover will cost—or save—the average
cacy for prevention. hospital an additional $337 500.17
Multiple studies have shown that up to 34%
BULLYING AND THE BOTTOM LINE of nurses18 leave or consider leaving the pro-
fession as a result of bullying. And even if they
Even if the “2030 problem” is not yet on stay, the fallout from bullying behaviors—
everyone’s radar, nurse bullying can have including absenteeism, decreased productiv-
serious implications for an organization. Even ity, and medical and legal expenditures—
in well-staffed hospitals, the presence of a bul- costs US health care organizations an average
lying culture may be contributing to poorer of $11 581 per nurse per year.19
outcomes across the board.14 Financial outcomes aside, a bullying cul-
Patient satisfaction scores are directly tied ture is bad for physical and emotional health.
to Medicare reimbursement and hospital Nurse bullying has been linked to psychoso-
reputation. Nursing satisfaction is tied to matic symptoms such as headaches and fre-
these scores. According to a 2009 study quent illness, depression and anxiety, reduced
commissioned by the Hospital Consumer As- productivity, absenteeism and fear of going to
sessment of Healthcare Providers and Systems work, impaired relationships, poor quality of
(HCAHPS),15 “The nurse work environment life, and suicide.20 These comorbidities pre-
was significantly related to all HCAHPS vent many nurses from bringing their best to
patient satisfaction measures. Additionally, work. Bullying can decrease quality of care
patient-to-nurse workloads were signifi- and collaboration. It denigrates the profes-
cantly associated with patients’ ratings and sion and the organization. At the very worst, it
recommendation of the hospital to others, could threaten patient safety, as patients are
and with their satisfaction with the receipt of at the end of the decisions made by nurses
discharge information.” and other clinicians.

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278 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019

Other hidden and indirect costs must be bedside. In this emerging paradigm, a nurse
considered. Bullying sacrifices an organiza- completes 3 to 5 years of bedside clinical prac-
tion’s ability to achieve consistent, high- tice before changing positions to advance
quality outcomes associated with high relia- practice, leadership, education, or other
bility science. It is not possible to achieve the roles.
goal of high reliability in health care in envi- Nurse bullying is a pervasive, systemic
ronment that permits or promotes bullying. problem that will not disappear overnight. But
The defining characteristics of a highly reli- it has no place in the nursing profession. Bul-
able organization include healthy work envi- lying needs to be addressed in nursing schools
ronments, emotional and physical safety, and and at every point on in a nurse’s career.
a culture that is “just,” where it is safe and Table 2 contains a list of strategies organiza-
expected to speak up. tions may consider implementing to address
Nurses invest years of time and often thou- nurse bullying.
sands of dollars into their education and train- All stakeholders, from school faculty to
ing. But 43% of newly licensed nurses leave hospital administration to nurses themselves,
their first jobs within the first 3 years.21 Where need to work together to create a safe, posi-
are they going? Possibly to health care orga- tive environment for nurses to reach their full
nizations that put an emphasis on a positive potential. In the words of workplace bullying
work environment, and take a stand against expert Dr Renee Thompson, “If we are going
bullying and incivility. Many nurses work to finally eliminate bullying and incivility, we
toward career destinations other than the all need to do our part.”22

Table 2. Strategies for Addressing Nurse Bullying

1. Admit there is a problem. Bullying will thrive so long as no one speaks about it, and even if you do
not think it is going on at your organization, it could crop up at any time. Nurse bullying is a
systemic issue in the profession, and every workplace is at risk.
2. If possible, eliminate any situational factors that may make bullying worse, such as work overload.
Stress and fatigue can bring out the worst in people.
3. Start at the top. Train leaders in clear communication and collaboration skills. Make sure they are
modeling the behaviors they expect their employees to follow.
4. Commit to a zero-tolerance policy for those bullies or bad actors who do not change. Name the
specific behaviors included in your definition of bullying so that all staff members are clear on the
expectations. Ensure there are policies in place detailing how bullying should be reported and
addressed.
5. Foster a respectful environment where nurses feel comfortable reporting acts of bullying to their
leaders, or feel supported to address it directly themselves. Take all reports of bullying seriously
and respond to them quickly. Be clear with people who report bullying that you believe them,
first and foremost.
6. Address bullying behaviors as they happen, in a firm but not accusatory manner. Take a systems
approach, bringing Human Resources into the situation early and often.
7. Encourage nurses to seek behavioral health services if needed. Workplace bullying can seriously
impact a person’s mental and physical health.
8. Include coworker incivility in your social and online media policy. Make it clear you will not
tolerate any personal attacks on fellow staff, in person or online.
9. Encourage nurses to hold each other accountable. There are often more bystanders than bullies,
so empowering nurses to call out bullying behaviors can change the culture from the inside out.

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 Our Own Worst Enemies 279

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