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Call a Code Bully

Educating nurses to speak up against horizontal violence

I began my career working as a registered nurse. This was my first exposure to a professional nursing setting.  Working in a field dominated by women, I anticipated a culture of open mindedness and peer support to help me grow both as a nurse and as an individual. However, to my disappointment it turned out to be an opposite culture of what I was expecting. At that point, I grasped the meaning of the idea that "Nurses eat their young."  

Surrounded by toxic negativity, I realized I had become an easy target to other experienced nurses who either wanted to take control over newly hired nurses or who felt they needed to be the center of attention.  Horizontal violence in nursing is not a new issue. Most nurses are aware of the problem and may have been a victim during some point in their career. Everyone agrees that the culture needs to change, but we don't have the tools to start the change process. This article will provide steps which nurses can use to prevent violence between peers.

Horizontal violence can be defined as disruptive and inappropriate behavior demonstrated in the workplace by one employee to another who is in either an equal or lesser position.1 As we all know, nursing is perceived as the most trusted profession, and nurses do indeed care, advocate, and make positive change for their patients. Moreover, as patients' advocates, nurses are ready to move mountains in order to provide the best quality of care to their patients. However, despite being strong advocates to their patients, nurses have difficulty speaking up against violence or bullying between peer nurses. It is time to change that.

Signs of Abuse
To be able to prevent abuse in the nursing workforce nurses have to be able to recognize signs of abuse, which can range from bullying, gossiping, harassing, joke teasing, portraying overt body language, intimidation and threats to betraying confidences. All are characteristics of horizontal violence.2  Moreover, bullying consists of three roles. The "bully" or the perpetrator is a person who persistently is bullying another person at least once a week for at least six months.3 As a result, the victim personalizes the bully's aggression rather than identifying the abuse.2

SEE ALSO: Bullying Interventions E-book

The last role, which is equally important, is that of the bystander who watches the abuse and does not take any actions. Any nurse who is a witness to any kind of abuse and does not take any action against it contributes to horizontal violence and empowers the bully.2 In addition, research has shown horizontal violence can have detrimental consequences on health such as physical and psychological impact. Also, horizontal violence does not only affect the victim but the employer as well. It was found that victims of horizontal violence tend to have lower levels of job satisfaction, absenteeism from work, and a high staff turnover rates.

Several methods for prevention of horizontal violence in nursing, which have been suggested by multiple studies, are mandatory education of staff and anti-bullying policies. Even though there are few evidence-based interventions for addressing horizontal violence, research does exist on evidence-based practice in education. According to Longo, 24 % of the nurses, 21.3 % of the physicians, and 20.8 % of the executives stated that a needed strategy to decrease bullying was educating nurses to improve their working relationships by improving their communication skills4.  Education can be utilized as the power tool in combating horizontal violence. In addition, some studies suggest educating staff about horizontal violence and proper communication skills, especially when dealing with disruptive behaviors can facilitate in creating a healthy workplace and positive outcomes.4   After all, the ultimate goal for nurses is to deliver optimal patient care and this can be accomplished only if culture of nursing is changed by healthier work environments.

In addition, according to Longo eight skills for effective communication are of as essence for nurses in preventing violence in the workplace.  These skills include  (a) listening to the other person; (b) asking open ended questions to gain more in-depth information; (c) asking closed questions to gain facts; (d) clarifying in-order-to get more details; (e) paraphrasing so that meaning can be interpreted; (f) using facilitators to encourage continuing dialogue; (g) assessing non-verbal; and (h) using silence to promote thinking. Furthermore, education can help employees when confronting staff with disruptive behaviors. 4 As Longo  states the confrontation should occur as soon as possible after the incident and during the dialogue, respect and privacy must be maintained.  In addition, it is important when addressing disruptive behaviors, a mutual understanding of what occurred needs to be established, and both parties need to describe their feelings that resulted from the behavior as well as the impact the behavior had on them.

Code Bully
Equally important strategy in preventing horizontal violence and combating disruptive behaviors is initiating anti-bullying policies. Therefore, one of the biggest responsibilities of managers and administrators should be enforcing the code of conduct for the staff. According to Longo calling a "Code Bully" can provide support to nurses who are being bullied.   For example, if a nurse is being victimized by another healthcare worker, a code can be called to signalize that their behavior is unacceptable.4  In addition, self-awareness helps in redirecting emotions and behaviors toward a more positive manner.

When the code of conduct is clearly outlined with acceptable and unacceptable behaviors, it will be easier for the staff to reach self-awareness when dealing with violence. Establishing code of conduct will facilitate in changing the culture in nursing workplaces, facilitating self-awareness, and assisting staff to take responsibility for their actions.

Now, more than ever, it is time to stand up and say no to horizontal violence in our profession. Our communities rely on us and we should rely on each other as well. We hold the power of knowledge and skills, and if we are able to influence patients and doctors when safety and quality of care are at stake, then we must influence each other to care and respect each other. After all, healing others starts from healing ourselves first. While we do recognize that there are challenges in the nursing field such as stress, frustration, control and powerlessness, among others, we must actively seek to create a better working environment especially for the young nurses.

In an environment where a lot of things are out of our control, the way nurses relate to each other should be with care, compassion and mutual benefit. Therefore, preventing horizontal violence in the nursing workforce and empowering each other by caring and nurturing each other will result in a healthy culture, a better profession, better patient care, an increase in nurse retention rates, and a better job satisfaction.

1. Christie W, Jones S. Lateral violence in nursing and the theory of the nurse as wounded healer. The Online Journal of Issues in Nursing. 2014;19.
2. Egues A, Leinung E. The Bully within and without: strategies to address horizontal violence in nursing. Nursing Forum. 48(3), 185-190.  doi: 10.1111/nuf.12028
3. Lee Y, Bernstein K, Nokes K. Bullying in the nursing workplace: applying evidence using a conceptual framework. Nursing Economics. 2014; 32(5), 255-266.
4. Longo J. Combating Disruptive Behaviors: Strategies to Promote a Healthy Work   Environment. The Online Journal of Issues in Nursing. 2010; 15.                OJIN/TableofContents/Vol152010/No1Jan2010/Combating-Disruptive-Behaviors.html

Amra Mekic is enrolled in a masters in nursing education program at the University of Hartford.

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I strongly believe that micromanaging is a form of bullying. Leaders who are so unsure of changing into the future, are set in their ways and think that their way of thinking and acting are the only way things can be accomplished are bullies. They force their methods on everyone.

Sueanne ,  DNPDecember 14, 2016
Dallas, TX

Nursing is my second career. My first career was lab & public health research. I was shocked, frankly, at the amount vehemency of bullying that happens in nursing. In NO other field is that sort of behavior tolerated. I find this article less than helpful.

The problem is not a lack of interpersonal communication skills. I communicate just fine, but when I had no confidence in my nursing skills and knowledge as a new grad, I couldn't possibly stand up for myself to experienced, "star" RNs. I felt alone, isolated and my already shaky confidence nosedived further.

The solution is for nurses to just grow up and stop acting like they're in high school - and management needs to stop tolerating, nay - encouraging! that behavior. We call ourselves a profession. For Pete's sake, stop acting like teenagers and act like professionals. We are all under stress - don't make it worse for each other.

I kid you not - in any other field, people would get fired for the type of garbage I've seen nurses pull toward each other.

(I am, at this point, a successful, well-liked ICU nurse w/ my CCRN. I dug my heels in and overcame. I shouldn't have had to.)

Kelly RNOctober 28, 2015

Sucra may have a good point. "The behavior of the workers...reflects the management style of the supervisor". Our facility had bullies all the way from the floor RNs up to the DON. I reported bullying and my AMgr (being a mgr) turned it around on me in my annual eval saying I maintained the misconception of bullying which negatively affected my work performance. Yeah right. Amazing, since every employee on our unit was aware of the bullies/bullying.

Car How,  RNII,  HospitalOctober 28, 2015
Fresno, CA

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