Nursing continues to have its share of bullies who dishonor the profession, impact recruitment and retention of nurses and nursing students, and negatively affect the workplace environment for nurses in general. The adage, "nurses eat their young" is one of disservice to the ethical nurses who work with dedication and good will.
As nurse educators for almost 2 decades, we have seen the demoralizing effects of bullying on nursing students' personal and professional lives, including but not limited to issues related to anger management, concentration, depression, eating disorders, family relationship disruptions, generalized anxiety and mood disorders, self-doubt, and sleep disorders.1 It is inconceivable and alarming that close to 80% of registered nurses have experienced workplace bullying.2 Yet it is true.
We have seen how "predatory alliances" in educational settings have allowed bullying to be hidden, and we have witnessed bullies rewarded in the workplace3 across nursing settings. The existence of bullying paralyzes interference with the facilitation of education and student learning. Whether bullying takes place in didactic or clinical settings, the effects of a hostile learning environment are personalized and long remembered.1 Hence, nursing students and new graduate nurses need to learn about bullying before entering the workforce. They must learn why bullying occurs and how to take power away from bullies.
To that end, driven by personal experience as well as experiences voiced by colleagues and students, the authors developed workshops on anti-bullying to be incorporated into nursing curricula. The goal is to create an ethically safe and informative learning environment for all nursing students regardless of ethnic and/or racial background.4,5 Learning that is transformative can occur during anti-bullying workshops for nursing students. These workshops can influence how students think about and conduct themselves in practice, and enable them to become change agents to diminish and possibly end bullying behavior. Facilitating how to deal with bullying is salient for nursing students, and especially for nursing students of minority background who feel a lack of power within their school and/or work environments.5 It is our duty to prepare the nursing leaders of tomorrow to heal their personal and professional environments.
We used long established theoretical frameworks of mentoring6 and personal and organizational empowerment7 to develop workshops. These workshops were created with specific objectives to: explain terms associated with bullying behaviors; identify underlying theories of bullying behavior; recognize covert and overt signs of bullying; practice techniques of empowerment through appropriate communication and behavior; and learn how to negotiate personal and professional political landscapes regardless of nursing practice level and specialty.4,5
A variety of high-impact educational practices8 are used in each workshop to engage affective, cognitive and psychomotor domains of learning. These practices include case studies, collaborative group work, journaling, role-playing and self-reflection. Bullying examples and theory, conflict management and resolution, communication, listening enhancement, and healing and self-care strategies are addressed. The 2-hour workshops are conducted as part of teaching methodology in the last clinical course in the undergraduate associate degree nursing program, as well as with RN-BS nursing students enrolled in the community health nursing course. Institutional Review Board approval is granted for workshops.4,5
Each workshop, held during a 2-hour post-class session, begins with garnering participant consent. Workshop participation is voluntary; however, students are eager to participate and less than 0.05% choose not to attend. A Likert scale, knowledge-based pre-test questionnaire follows, relating to students' self-identified experiences and knowledge about the definition of bullying, types of bullying, and bullying encounters. The same questionnaire is administered at the conclusion of the workshop, and results are compared.
The post-test has a section for comments, allowing for collection of qualitative data. The richness of this qualitative data and often poignant vignettes have been incorporated into subsequent workshops as role-play and "pair-and-share" opportunities, and as "stop-think-reflect" 5-minute moments. The pre-test/post-test model allows the presenters to evaluate participants' knowledge across both associate degree and RN-BS degree programs.
After pre-tests, each workshop begins with a demonstration of a bullying experience, with presenters engaging in bullying behavior. A request for immediate feedback often leads to participant acknowledgment of several, but not all, manifestations of bullying behavior that are demonstrated. The workshop continues with a 30-minute lecture that incorporates discussion of the objectives. Students hear that bullying is not limited to physical violence, and can in fact be hard to identify and subtle. A bully may not even raise his or her voice while behaving in a condescending manner, engaging in constant criticism, responding curtly or angrily to reasonable requests, sabotaging the victim, taking credit for the victim's work, or withholding important information about patient care.
SEE ALSO: Earn CE: Nurse to Nurse Workplace Bullying
Possible factors contributing to horizontal violence are explored as participants learn that interpersonal factors leading to bullying include ambition, jealousy, lack of respect, and personality traits. Institutional factors addressed include inadequate staffing levels leading to increased stress; inadequate supervision; logistics and stresses associated with shift work (competing for the best shifts or holidays off); interventions requiring close physical contact; and pressure to reduce patient wait times. Discussion emphasizes that numerous factors work to perpetuate the culture of horizontal violence, including bullies who are highly manipulative, so that it can be difficult for the victim to confront these behaviors. Labeling of behavior, emotions and reactions, the roles of bully, victim and standby (those who do nothing when witnessing bully behavior) are discussed. Potential consequences for the victim of bullying, and subsequent personal and professional effects, are addressed as well. Throughout the workshop, the primary emphases are that bullying is not the fault of the victim, and the victimization of a single person negatively impacts that person's life as well as that of the entire work environment.
The second portion, which constitutes the majority of the workshop itself, is interactive. Participants work as teams to provide examples of bullying behavior they have witnessed. Students are then provided with written case studies and allowed, in role play, to practice responding effectively. They alternate among the roles of bully, victim and standby. This piece of the workshop lasts approximately 15 to 20 minutes. It is followed by a 10-minute discussion about professional workplace behaviors and how RNs may contribute to creating a positive and supportive environment, including developing a mentoring system, holding bullies accountable, making sure workload is distributed evenly, refusing to publicly criticize coworkers, holding people accountable for their actions, and developing a mentoring system.
Approximately 10 minutes are then spent introducing and practicing stress-relieving techniques such as breathing exercises and mindfulness, and discussing the importance of self-care. The workshop concludes with a post-test and optional course evaluation. Surveys completed by the workshop participants have consistently reported increased knowledge about methods of appropriate communication in bullying, self-protective methods, and the various aspects of bullying.5 Interestingly, the request by RN-BS nursing students for bullying workshops is increasing over time. The comparison of collected qualitative data among student participants enrolled in the associate degree program versus that of student participants enrolled in the RN-BS program will be discussed in a subsequent article.
A Growing Need
Much work needs to be done to combat bullying. Nursing as a profession is not immune to the harm perpetuated by bullies, and the practitioners of the future must be better armed to take on the role of anti-bullying change agents. It is incumbent upon educators to consider instituting anti-bullying workshops for nursing students across curricula at all levels of education to forge a true future of caring for all.
1. Egues AL, Leinung EZ. Anti-Bullying workshops. Nursing students learn to better conduct themselves in practice. ADVANCE for Nurses. http://nursing.advanceweb.com/Features/Articles/Anti-Bullying-Workshops.aspx
2. Vessey JA, et al. Bullying of staff nurses in the workplace: A preliminary study for developing personal or organizational strategies for the transformation of hostile to healthy workplace environments. J Prof Nurs. 2009;25(5):299-306.
3. Hutchinson M, et al. Workplace bullying in nursing: Toward a more critical organisational perspective. Nurs Inquiry. 2006;13(2):118-126.
4. Egues AL, Leinung EZ. The bully within and without: Strategies to address horizontal violence in nursing. Nurs Forum. 2013;48(3):185-190.
5. Egues AL, Leinung EZ. Antibullying workshops: Shaping minority nursing leaders through curriculum innovation. Nurs Forum. 2014;49(4):240-245.
6. Benner P. In: From Novice to Expert. Excellence and Power in Clinical Nursing Practice. Commemorative edition. Upper Saddle River, NJ: Prentice-Hall, Inc.; 2001.
7. Kanter RM. In: Men and Women of the Corporation. 2nd ed. New York: Basic Books; 1993.
8. Kuh GD. In: High-Impact Educational Practices: What they are, who has access them, and why they matter. Washington, DC: LEAP Publications of the Association of American Colleges and Universities; 2008.
Aida L. Egues is an associate professor in the Department of Nursing at New York City College of Technology of The City University of New York. Elaine Z. Leinung is an assistant professor at the college.