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    Reversing the bullying culture in nursing

    Leaders within healthcare organizations are struggling to manage disruptive behavior and bullying in the workplace.

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    A DIRE SITUATION IS LOOMING in the US healthcare system. The country is bracing for a projected unprecedented shortage of more than 500,000 RNs by 2025, due in part to baby boomer nurses retiring at the same time as the demand for healthcare is rising. Moreover, despite the 3.3% increase in student enrollment and a stable RN vacancy rate of 8.1%, RN turnover rates range from 8.4% to 13.9%; and the demand for registered nurses still is expected to increase 2% to 3% annually.1 RN dissatisfaction and related intent to leave the work environment are believed to be key factors contributing to the shortage. Moreover, exposure to incivility, including workplace bullying, is one of the primary factors influencing RN dissatisfaction and turnover rates,2 and can be a reason why some leave the profession altogether.3

    INCIVILITY AND BULLYING BEHAVIORS IN THE WORKPLACE Evidence suggests workplace bullying and related disruptive behavior are commonplace, and on the rise. The combination of a busy healthcare setting, difficult patient situations, and the requirement for interdependent relationships can serve as a breeding ground for incivility and bullying behaviors.4 In response to a survey by the Joint Commission, more than 50% of nurses reported having been a victim of bullying and/or disruptive behavior at work, and more than 90% stated that they witnessed the abusive behavior of others.5 Despite the subsequent Joint Commission Sentinel Alert requiring healthcare facilities to design and implement a systemwide approach to ensure employee awareness of disruptive and/or bullying behaviors, bullying continues and still is perceived to be steadily on the rise.6 The implications for nurses' work environments are noteworthy, since the health and availability of nurses are vital for the provision of a safe environment for our most vulnerable population—the patients we serve.2,7,8

    Incivility is described as "rude or disrespectful behavior that demonstrates a lack of regard for others."4 If left unabated, more aggressive behaviors, such as workplace bullying, can flourish and acculturate within a unit, department, and even the organization at large. The definition of workplace bullying has evolved over the years, from behavior that included open physical assault or violence, to more subtle, even masked behaviors such as backbiting, blaming, disparaging, and exclusionary treatment meant to do harm to another.9-11 While a few researchers believe bullying only occurs horizontally among coworkers, the majority feel that a real or imagined imbalance of power between the bully and the victim is a necessary element of bullying behavior.10-13 What makes the phenomenon of workplace bullying separate and distinct from other disruptive behaviors, such as incivility or workplace violence, is that these behaviors are not random acts. They are intentional, occurring over a prolonged period of time, and targeted at an individual who is unable to defend himself. Although bullying may seem harmless to an untrained eye, a deliberate, ongoing pattern of negative behaviors can have a cumulative effect, leading to serious harm to the intended victim in the long run.10

    THE BULLY VICTIM Research from 2006 suggests bullying behaviors, particularly related to the transition of new graduate nurses, may be a manifestation of the traditional subordinate role of nursing within the medical model of healthcare,2 as suggested by the frequently used expression about "nurses eating their young." A 2007 study suggested that the contrary also might be likely—that victims could be vulnerable despite being above-average, talented, and/or energetic.14 The latter perspective may suggest a lack of self-esteem on the part of the bully, rather than the victim, and the perceived need to maintain status quo within the department or unit.

    CONSEQUENCES OF WORKPLACE BULLYING A 2005 article in the Journal of Business Ethics was titled "Sticks and stones may break your bones, but words can break your spirit."15 This reworked version of an old rhyme rings true when one examines the consequences of bullying in the work environment of nurses, that the consequences of bullying go well beyond the breaking of one's spirit, affecting the psychological and physical health and well-being of both the victims and the observers. Workplace bullying has been identified as a predictor for increased sickness absenteeism,16 cardiovascular disease, and depression.17 If targeted toward a victim over prolonged periods of time, it even may predict post-traumatic stress syndrome.18 Stress and physical symptoms, such as insomnia or digestive disturbances, often remain long after the bullying has stopped, which can result in nurses leaving or being forced out of their jobs.12

    For healthcare organizations, workplace bullying can trigger enormous expenses in time and money in response to absenteeism, high staff turnover, and lower productivity. This can translate into decreased employee morale, organizational apathy, lost employee productivity, and ebbing employee loyalty, and even may lead to an increase in employee grievances and Equal Employment Opportunity Commission cases. Although not specific to nursing, nationwide costs of productivity loss related to the consequences of bullying in the general population is estimated at $5 billion to $6 billion annually.19 Yet, despite the deleterious effects for both individuals and organizations at large, these behaviors can continue unabated or ignored.

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