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The Persistent Problem of Nurse Bullying

Nurse leaders should be advocates for their staff members

Victims of bullying often feel demoralized, alone, frightened, and insecure.  Especially, vulnerable to this kind of victimization are novice nurses working within the first two years of their career . 1 The International Council of Nurses Code of Ethics remind us that inherent in nursing practice is the right to be treated with dignity and work in a health care environment absent of rivalry, antagonism, and hostility. 2  Ethical nursing leadership requires leaders who create and support a healthy work environment, recognize generational differences, address moral distress, attend to nurses' workload, physical working conditions, and work environment.

Watson argued that a fine line exists between bullying and strong management in which an active leader expects staff to meet reasonable demands and expectation of employment. 3 In doing so, a blur exists between ingrained attitudes of managers and staff and perceived line of managing and bullying. On the other hand, Hunt and Marini link incivility as the precursor to a continuum of antisocial acts that contributes to bully behaviors. 4 The Workplace Bullying Institute describes workplace bullying as: Repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators.  It is abusive conduct that is a) threatening, humiliating, or intimidating, b) work interference-sabotage-which prevents work from getting done, or c) verbal abuse. 5

Incivility constitutes deviant behaviors that are low in intensity and involve undermining a colleague's credibility, giving people the silent treatment, publicly reprimanding , ignoring a colleague's request, and uttering, demeaning language or voice tone that violates works norms of respect.6

Creating and Supporting a Healthy Work Environment

To establish and maintain acceptable workplace behaviors, the challenge for nurse leaders is to create and promote a healthy work environment in which nurses have autonomy and authority.7 Kroth, Boverie and Zondlo suggested a healthy work environment begins with the hiring process whereby leaders clearly outline organization expectation, delineate fair treatment of employees, attend and meet staff at orientation, and establish mentoring programs. 8 Of equal importance to nurse leaders is modeling behaviors that give staffs permission to have fun and humor in the workplace while celebrating events (Nurses' Week/service awards) and social activities (holidays/staff weddings/baby showers/hospital marathons).

A successful nurse leader role models an open-door policy of accessibility, listening and communicating; an approach that invites staff into his or her office to problem solve individually, in groups or teams. Equally important, to nurse leaders is breaking down hierarchies by eating with staff, allowing self to be seen as real people, showing positive attitudes, recognizing staff efforts, and getting to know staff at a personal level.  Effective leadership involves avoiding micromanaging, discouraging disrespectful behaviors, treating staff fairness and equitably. 8,9

Recognizing Generational Differences

A triumphant leader recognizes the similarities between generations, not the difference; for example, all generations have similar values, would like respect, ardently want trustful  leadership, desire feedback, and wish for recognition of losses resulting from change. 10,11  For example, losing one's intravenous (IV) skills or techniques because of the introduction of new IV products presents challenges to every generation of nurses.  As a result, of the new IV product the nurse may need to reestablish  personal confidence with the procedure or relearn IV angle insertion or method of advancing the needle.

To overcome these challenges a nursing leader listens for feedback, offers support, arranges for in-services, and allows time to relearn the new skill. Above all else leaders ought to recognize the nurses' need to learn-nurses want self-assurance that they are knowledgeable, qualified to do the job well and are meeting their standards of practice. Bae, Mark and Fried suggested that leader support and supervision influence both workgroup processes and organizational effectiveness linking quality of nursing care to positive patient outcomes. 12 Andrew argued that early clinical learning combined with experience and reflection produces a clinical imprint on the nurses' long-term professional development in which they transfer theories into clinical practice.  13

Addressing Moral Distress

Magnussen suggested that nurses are often torn between professional commitment and their personal responsibilities to practice safely, competently, compassionately while providing ethical care. 14 When nurse leaders fail to take seriously, the nurse values the result may be moral distress in which the nurse "knows the ethically correct action to take but feels powerless to take that action." 15 Although the nurse may feel a sense of isolation, frustration, and anger Epstein and Delgado suggest that the positive side of moral distress is increased awareness of ethical problems. 

Ethically nurses' value, helping others, acting as a patient advocate, empowering patients and families with knowledge, makes differences in patient center care, and practicing with compassion. 14 Left unchecked moral distress tends to linger and may become moral residue.  Moral residue has the potential to linger in the nurses' thoughts and view of self-causing numbness to ethically challenging situations (removing the patient from a respirator).

To overcome moral residue and distress nurse leaders must embrace moral courage.  Moral courage is the act of creating a work environment that enables nurses to remain focusing, on the patients, families, and communities. 16 Other solutions for nurse leaders to consider involve consulting an ethics consultant to help staff identify moral distress, encourage open discussion, identify barriers to change, and create a plan for action. 15

Attending to workload, physical working conditions, and work environment, planning nursing workload should reflect on situating nurses in the right assignment for their skills, interests, and talents. 10 Lancman, Mangia and Muramoto found that the intense pressure to provide care quickly and document in a timely manner often resulted in conflict and aggression among unprepared staffs.  Nurses are frequently exposed to attack, threats, and abuse from peers, families, patients, and supervisors due to environmental factors, such as, inadequate security, long wait periods, inadequate staffing, and no overtime policy.  17  

Welcoming Work Environment

Nursing aides working under the direction of nurses are especially vulnerable to these behaviors.  Although one cannot control the budget of an organization poorly managed internal stratification of staff has serious consequence for organizational and ethical climates. 18 Garcia et al. found these healthy organizations have a welcoming work environment in which policy directs nurse leaders to an organizational climate of respect without rules that control staff continually or strictly monitoring their actions.

It has long been suggested that explanation for bullying behaviors among nurses result from the ways nurses are socialized into nursing, unresolved anger, oppression, powerless, and an unequal power hierarchy. 19 Similar studies of bullying behaviors reveal that these behaviors are not going away.  As a result, nurse leaders must alter their approaches to spotlight positive organizational and ethical climates in which bullies are included in the change; transformation happens from nurse leaders who model honesty, inspiration, passion and have a vision.

Workplace bullying has serious staffing consequences for nurse leaders.  Persistent patterns of bullying behavior interfere with a nurse's pursuit of dignity and respect.  Ethical nursing leadership requires leaders who can create and support a healthy work environment in which generational differences, moral distress, workload, physical working conditions, and work environment are in balance.



1. Grubb P, Gillespie G, Brown K, Shay A, Montoya K. Qualitative evaluation of a role play bullying evaluation. OUD Consultancy; February 2014; Miami, FL.

2. International Council  f Nurses. (2012). The ICN Code of Ethics for Nurses. Retrieved from

3. Watson (2015). The concept of bullying is gaining recognition in the field of nursing leadership.  Retrieved from

4. Hunt, C., & Marini, Z. A. (2012). Incivility in the practice environment: A perspective from clinical nursing teachers. Nurse Education in Practice, 12(6), 366-70. doi:

 5. Workplace Bullying Institute. (2014). The wbi definition of workplace bullying. Retrieved from

 6. Welbourne, J. L., Gangadharan, A., & Sariol, A. M. (2015). Ethnicity and cultural values as predictors of the occurrence and impact of experienced workplace incivility. Journal of Occupational Health Psychology, 20(2), 205-217. Retrieved from

7. Ritter, D. (2011). The relationship between healthy work environments and retention of nurses in a hospital setting. Journal Of Nursing Management, 19(1), 27-32. doi:10.1111/j.1365-2834.2010.01183.x

 8. Kroth, M., Boverie, P., & Zondlo, J. (2007). What Managers Do to Create Healthy Work Environments. Journal Of Adult Education, 36(2), 1-12.

 9. Becher, J., & Visovsky, C. (2012). Horizontal violence in nursing. Medsurg Nursing, 21(4), 210-3, 232. Retrieved from

. American Management Association. (2015). The myth of generational differences in the workplace. Retrieved from

11. LeDuc, K., & Kotzer, A. M. (2009). BRIDGING THE GAP: A comparison of the professional nursing values of students, new graduates, and seasoned professionals. Nursing Education Perspectives, 30(5), 279-84. Retrieved from

 12. Bae, S., Mark., & Fried, (2010). Impact of nursing unit turnover on patient outcomes in hospitals. Journal of Nursing Scholarship, 42(1), 40-9. Retrieved from

 13. Andrew, N. (2013). Clinical imprinting: The impact of early clinical learning on career long professional development in nursing. Nurse Education in Practice, 13(3), 161-4. doi:

14. Magnussen, Carol F. Rocker, PhD, MHS, BN, RN, works at the Vancouver Island Health Authority and University of Victoria.H. J. (2014). The moral work of nursing: Asking and living the questions. Victoria,  Canada: Promontory Press Inc.

15. Epstein, E.G., & Delgado, S. (2010) "Understanding and addressing moral distress" OJIN: The Online Journal of Issues in Nursing 15 (3). doi 10.3912/OJIN.Vol15No03Man01

16. Edmonson. C., (2015) "Strengthening moral courage among nurse leaders" OJIN: The Online Journal of Issues in Nursing (20) 2. doi 10.3912/OJIN.Vol20No02PPT01

 17. Lancman, S., Mângia, E. F., & Muramoto, M. T. (2013). Impact of conflict and violence on workers in a hospital emergency room. Work, 45(4), 519-527. doi:10.3233/WOR-131638

18. García, I. G., Castillo, R., & Santa-Bárbara, E. (2014). Nursing organizational climates in public and private hospitals. Nursing Ethics, 21(4), 437-446.

 19. Stokes, P. (2010). Nurturing new nurses: don't eat your young!. Oklahoma Nurse, 55(4), 13.

Carol F. Rocker works at the Vancouver Island Health Authority and University of Victoria.

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I agree the young also bully older and cliques are worse than high school!

Becky ,  RNApril 23, 2015
Spokane, WA

Great artical, finally one was published recently. I have not worked since my last job in a home care agency resulting in Major Depression disorder. My Attorney said, I could have sued them under (C.I.P.A). Have researched Bullying and have many articles on this. Basically, it says it is a dysfunctional work place,and their are many tell tale signs. When your boss is a serial Bully, they have an antisocial personality type and they need help. I could go on and on. Former Victim

Gail Staub,  Registered Nurse,  NoneApril 23, 2015
None, NJ

Excellent article. Workplace bullying is a very serious issue. I was surprised to see it discussed. From personal experience, it was tough to endure when the perpetrator is upper management. Often trying to bridge the gap between organizational needs and patient safety. I always pressed towards patient safety and practicing with a conscious. In the end, the bullying coercion from my organization stopped. But it came with a price of being isolated, ostracized from fellow staff, taken off the schedule, threatened to be fired, written up for insubordination, to finally not being asked to do something to unethical and unsafe. It took courage. I became very familiar the nurse practice act and american nurses assn. Great article for bringing this to the forefront.

shanita clark,  rnApril 23, 2015

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