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Course: Nurse-to-Nurse Workplace Bullying Return to Course Outline

Nurse-to-Nurse Workplace Bullying

APPLES each day keeps bullies away

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Learning Scope #526
1 contact hour
Expires June 8, 2017

You can earn 1 contact hour of continuing education credit by: 1) Taking the test online. Go to 2) Send the answer sheet to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406, with a self-addressed, stamped envelope; fax 610-278-1426. (Answer sheets can be downloaded from If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70% or better.

Merion Matters is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The planners and authors have completed a disclosure form and report no relationships relevant to the content of this article.

Learning Objectives:
The goal of this continuing education activity is to educate nurses about the prevention of nurse-to-nurse bullying in the workplace. After reading this article, the nurse learner will be able to:
1. State the conceptual definition of workplace bullying.
2. Discuss personal accountability and how to adopt a personal zero tolerance policy for workplace bullying.
3. Take action using the APPLES Intervention when confronted with workplace bullying.

Bullying negatively affects the emotional and physical well-being of nurses and patients, and it financially taxes healthcare organizations. Bullying represents such a significant danger to national patient safety goals that the Joint Commission issued two Sentinel Event Alerts requiring healthcare organizations to address it.1,2 Industry research shows that healthcare workplace bullying negatively impacts patient safety.3 Nurse-to-nurse workplace bullying has gained international attention as a particularly negative practice undermining the health and safety of nurses and patients.4-7

Scope and Significance
A recent survey found that workplace incivility has been experienced by more than 84% of registered nurses.8 More than 26% of RNs surveyed in the same study acknowledged that they had initiated hostilities to another person.8 Other studies have reported lower incidences of nurse-to-nurse bullying, but several found that respondents who met research criteria for having been bullied did not recognize or indicate that they had been bullied.9

Relevance to Nursing
Nurse-to-nurse workplace bullying is strongly correlated with decreased productivity, losses of commitment, diminished morale, reduced job satisfaction, and intent to leave the profession or organization.3,8-10 Because workplace bullying is a prevalent, relatively accepted and conceptually ill-defined behavior, recipients may not recognize bullies' actions and motivations as unacceptable victimization; these factors contribute to underreporting and underrecognition of the impact of workplace bullying.6,9

The definition of workplace bullying operationalized here was developed from the applicable literature to increase nursing knowledge and identification of nurse-to-nurse workplace bullying:8-12 Workplace bullying is the overt or covert psychological abuse of a coworker, supervisor or subordinate using verbal and nonverbal behaviors; repeatedly and over a period of time, with the intent to humiliate, isolate, demoralize, intimidate, punish and otherwise undermine and disrespect the targeted person or victim.

Physical assaults are not included in the definition of workplace bullying because they are usually considered criminal acts and should be immediately reported to the appropriate law enforcement agency and handled according to the prevailing law in the victim's jurisdiction.12,13

Numerous terms are used in the literature to describe behaviors that meet the operational definition of workplace bullying used in this article. These include horizontal violence, lateral violence, mobbing, ijime (the Japanese term for bullying), negative workplace behaviors, psychological violence, and workplace incivility.4,8,10,11,14-16 Throughout this article, workplace bullying is used as the single term to describe all behaviors meeting the operational definition.

Literature Review
A literature review sought to analyze current research on nurse-to-nurse workplace bullying, to translate evidence into strategies to improve nurse-to-nurse relationships, and to create needed change. Addressing nurse-to-nurse bullying from this perspective creates the potential for positive change in the culture of nursing. This review was organized around six distinct themes that emerged from the available literature on workplace bullying in general, and nurse-to-nurse bullying specifically.

The literature shows the following about bullying: 1-3,5,7,12,14
• It is widespread and multidimensional.
• Bullies hold formal or informal power and authority.
• Victims of workplace bullies are both targets and witnesses.
• Bullies are cognizant of their behaviors.
• Bullying is an intentional act.
• Bullying results in significant financial costs for organizations.
• Bullying diminishes patient care efforts.
• Managers, coworkers and subordinates are sources of workplace bullying, and their intended targets are not the only victims; people who observe workplace bullying suffer negative effects comparable to the intended targets.3,7,12
• Bullies may directly target patients by making negative remarks to them.15

On a broader scale, workplace bullying is correlated with decreased productivity and occupational commitment, lowered morale and reduced client or patient satisfaction.5,6,12,15,16,17 It is also associated with increased system expenditures. Healthcare organizations and the people working in them have a significant duty to advance patient safety through improved communication.1,2,3,7,15,16

Research focused on nurse-to-nurse bullying has found considerable diversity in the demographic profiles of victims, including variables such as recent graduate status, significant RN experience and/or education, and age (nearing retirement).7,9,10,15,17 Diversity has also been noted in terms of practice area. RNs and nurse managers from emergency departments, intensive care units, medical/surgical areas, operating room/post-anesthesia care units, and obstetrics areas all reported nurse-to-nurse bullying.7,8,15,17

Documentation that power inequities are necessary for workplace bullying to occur is disparate in the literature; people who bully are generally more powerful than targets.9 However, the expected power differential is not always found. One study of workplace bullying target personalities discussed the Bottom-Up Victimization Theory in which workplace bullying is initiated by people who hold similar, or even lesser, organizational positions as their targets. This theory posits that "victimization from coworkers would result in subsequently increased victimization from supervisors."18 This perspective supports the thesis that people lacking formal authority over bullying targets may still be powerful and successful antagonists.18 In general, the literature shows that charge nurses, supervisors, managers and other nursing leadership are most often identified as workplace bullies or contributors to bullying through inaction when advised of maltreatment of nurses on their units.1,4-9,14,17,18

Both Targets and Witnesses
Workplace bullying increases feelings of concern, worry, distress, anxiety, dissatisfaction and tension among exposed staff.3-5,7,8,9,12,15-17 Bullying amplifies negative emotions including fear, anguish, apprehension and frustration among targeted nurses; targets often become disenfranchised and consider leaving their employment or profession.3-5,7-9,12,15-17 Witnesses to coworkers being bullied report personal humiliation and discomfort, significant workplace dissatisfaction, and consider leaving their employment or profession.4,5,7-9,12,15-17 Witnesses sustain levels of frustration and distress similar to those experienced by targets.3,5,12,16-18

Intentional Acts
As discussed previously, more than 26% of RNs in one survey disclosed that they had initiated at least one workplace bullying event.8 Workplace bullies deliberately craft interactions and situations in which targets are expected to be humiliated, isolated and unsupported.4,8,9 From victims receiving "hints" to leave their positions to becoming the subject of unwanted "practical jokes," research shows that workplace bullies are clearly cognizant and deliberate in their actions.4,7

Financial Costs for Organizations
Organizational expenses related to workplace bullying are high and include increased medical and workers' compensation claims due to stress.12 Unmeasured effects of workplace bullying negatively impact employee morale and engagement.12 This perspective is well supported by research; employees experience losses of dedication, efficiency and proficiency, resulting in relatively unmeasured organizational costs including increased use of sick leave, mental and emotional complaints, and intent to leave.3-5,8,9,15 One study estimated lost productivity exceeding 536 person-hours per year, per nurse.8 Multiplied by hourly wages and number of nurses employed in an organization, these costs represent staggering financial burdens for healthcare organizations.

Effects on Patient Care
The literature consistently shows that workplace bullying interferes with work relationships, productivity and teamwork.1-4,6,15-17,19 Patient care is negatively impacted because of disruptive behaviors including withholding information, escalating workplace conflicts, and sabotaging tactics that diminish teamwork and retention and increase absenteeism.3-5,8,10,12,15-17 In some instances, workplace bullies make offensive remarks directly to patients.15

Interventions Supported by Research
Evidence-based literature about interventions to prevent or decrease workplace bullying is limited. Research on characteristics of perpetrators of workplace bullying is also significantly limited. One study evaluated target personalities, but the researchers expressed concern that focusing on target personalities was tantamount to further stigmatizing victims of bullying.18 They found little statistical support for the conclusion that someone's personality was at the root of the bullying ordeal.18 The perception by nursing management was that targets of nurse-to-nurse workplace bullying were "accommodating and passive . (they) tended not to react to the behaviors but rather tolerated it . (and) looked to others to help."10,19

Established research has not specifically focused on interventions for workplace bullying, but some general advice for targets of workplace bullying can be gleaned:5,19,20
• Targets should carefully document all episodes of workplace bullying, including names of witnesses.
• They should consider reducing their relative isolation by bringing a supportive coworker to situations where bullying is probable.
• They should confront bullies about their unacceptable behaviors.
• They should practice stress reduction and health promotion behaviors, and empower themselves and their coworkers by supporting bullied coworkers.
• Obtaining an impartial mediator may be necessary and useful.

Organizational goals and policies to create a respectful workplace are essential. Organization leadership should participate in creating safe workplaces by learning what constitutes workplace bullying, how to manage inappropriate behaviors, and offering such training to all staff.1-3,5,15,19,20 Assertiveness training and team-building exercises are also recommended.3,5,19,20

Implications for Practice
Educational programs can help nursing leadership and staff nurses understand what constitutes workplace bullying and how to manage inappropriate behaviors.3,5,6,21 The APPLES Intervention can provide an organized approach to managing bullying behaviors, supporting educational initiatives, and increasing nursing knowledge and safety.3,5,6,19-21 I designed the APPLES Intervention to increase nursing knowledge about what constitutes nurse-to-nurse workplace bullying, the negative sequelae of nurse-to-nurse bullying, to offer useful strategies to improve nurse-to-nurse relationships, and to create safer, more respectful and healthier workplaces. The APPLES Intervention is focused on individual accountability and adoption of a personal zero tolerance policy.

Theoretical Framework and Methodology
Leininger's Theory of Culture Care defines the culture of nursing in the United States as "learned and transmitted lifeways, values, symbols, patterns and normative practices of the nursing profession."22 Nurses must be considered in terms of their diversity and as individuals from varied cultural perspectives - and within the organizational cultures where they function.22 Leininger's theory organizes the varied cultural milieu of healthcare and its overarching culture of caring for individuals.22-25

Leininger noted that "intercultural and intracultural violence will continue to erupt, particularly when cultural groups feel exploited or demeaned."23 Nurse-to-nurse workplace bullying is thus an expression of intercultural and intracultural violence.23 Repatterning or restructuring cultural care can empower and facilitate individuals and groups to effect needed changes.23 By seeking to understand diversities and universalities in personal and shared cultural worldviews, nurses can choose to provide cultural care to each other.22-25 Nurses can overcome nurse-to-nurse workplace bullying by repatterning and restructuring their interactions with each other using the APPLES Intervention strategy and their workplace social structure for empowerment.23

The APPLES Intervention
Address all Bullying: When someone overtly or covertly behaves in a bullying manner, it is important for targets and witnesses to address bullying behaviors immediately in a nonthreatening, united manner.3,5,16,17,19,21,26 Bullying includes verbal and nonverbal behaviors. Eye rolling, sighs and posturing are some nonverbal behaviors that can be used to disrespect and humiliate the target.20,21 Workplace bullying thrives when it is not quickly addressed.7,10,15,19,20

Practice Professionalism: Nurses must make a personal commitment to change unhealthy workplace interactions.3,5,20,21,26 No matter their role in bullying, nurses must take ownership for their own workplace behaviors and contributions to healthy or disrespectful environments.3,20,21,26 We cannot change the past, but we can change our future by making a personal commitment to stop nurse-to-nurse bullying starting with ourselves. Gandhi encouraged us to be the change we want to see in the world.

Protect our Peers: Nurses should support targets of workplace bullying by standing with them, touching their shoulder, or supporting them with their presence and words.2,20,21,26 Letting the bully and the target know that colleagues are present and engaged in the situation is powerful; an impartial mediator may be useful.5,20,21,26 We must refuse to simply remain a silent witness to the suffering of our colleagues. Instead, be present and engaged in the situation, remembering that bullies want to isolate and humiliate their victims.

Live out Loud: Gossiping, backstabbing and other disrespectful and isolating behaviors facilitate workplace bullying and must be stopped to create a healthy workplace.20,21,26 Nurses can change their culture by welcoming both positive and negative feedback, and by respecting people who offer feedback.20, 21 We must protect the safety of those who are brave enough to give us a peer evaluation, and when we give feedback, we must be respectful and have clear, positive motives.20

Educate our Emotions: Healthcare workers need emotional outlets other than bullying; the exploration of emotional education experiences, stress reduction and health promotion are recommended.5 Healthcare organizations must create more powerful respectful workplace goals and policies; these strategies are essential, and leadership should participate in creating safe workplaces by learning what constitutes workplace bullying, determining how to manage inappropriate behaviors, and offering such training to all staff .1-3

Stand up to Bullies: Nurses can overcome nurse-to-nurse workplace bullying by repatterning or restructuring interactions with each other; nurses must learn new ways of dealing with old problems, and they must encourage and support each other on this important journey using their workplace social structure to empower, rather than harm.23 By promoting healthier, more respectful work environments, interventions to decrease nurse-to-nurse workplace bullying will ultimately improve patient safety. 3,5,16,17,19,21,26

A Public Health Crisis
Nurse-to-nurse workplace bullying is a public health crisis affecting nurses, their patients and the organizations in which they work. This article presents an operational definition of workplace bullying. Personal, professional and organizational goals are profoundly and negatively affected by workplace bullying, as are healthcare system finances. Repatterning and restructuring interactions can effect change in the diverse cultures of nursing.

The APPLES (Address all Bullying, Practice Professionalism, Protect our Peers, Live out Loud, Educate our Emotions, Stand up to Bullies) Intervention strategy, based on evidence, provides a useful, organized, nonthreatening approach to create a personal zero tolerance culture for bullying behaviors. Integrating the APPLES intervention into the workplace social structure will allow nurses to become a vanguard on a journey to healthier, more respectful workplaces. This cultural journey may be the most important challenge nursing will ever face.

Deborah S. Elliott is a clinical level IV registered nurse in the emergency department at the Hospital of the University of Pennsylvania in Philadelphia, and a DNP candidate at Graceland University. She developed the APPLES Intervention.

1. The Joint Commission. Behaviors That Undermine a Culture of Safety.
2. The Joint Commission. Preventing Violence in the Health Care Setting.
3. Maxfield D, et al. Silence kills: The seven crucial conversations in healthcare.
4. Abe K, Henley SJ. Bullying (ijime) among Japanese hospital nurses: modeling responses to the revised Negative Acts Questionnaire. Nurs Res. 2010;59(2):110-118.
5. Cleary M, et al. Identifying and addressing bullying in nursing. Issues Ment Health Nurs. 2010; 31(5):331-335.
6. Longo J. Combating disruptive behaviors: Strategies to promote a healthy work environment. Online J Issues Nurs. 2010;15(1):5.
7. Taylor G. Workplace bullying: Are you part of the solution? Aust Nurs J. 2013;20(9):31.
8. Lewis PS, Malecha A. The impact of workplace incivility on the work environment, manager skill, and productivity. J Nurs Adm. 2011;41(1):41-47.
9. Simons SR, Mawn B. Bullying in the workplace: A qualitative study of newly licensed registered nurses. AAOHN J. 2010;58(7):305-311.
10. Lindy C, Schaefer F. Negative workplace behaviours: An ethical dilemma for nurse managers. J Nurs Manag. 2010;18(3):285-292.
11. Sellers K, et al. The prevalence of horizontal violence in New York State registered nurses. J N Y State Nurses Assoc. 2010;40(2):20-25.
12. Yamada DC. Workplace bullying and ethical leadership. JVBL. 2008;1(2):48-59.
13. US Legal. Assault law & legal definition.
14. Longton SL. Bullying and workplace violence. Nephrol Nurs J. 2014;41(3):243-244.
15. Hutchinson M, et al. Integrating individual, work group and organizational factors: Testing a multidimensional model of bullying in the nursing workplace. J Nurs Manag. 2010;18(2):172-181.
16. Roberts SJ. Lateral Violence in Nursing: A Review of the Past Three Decades. Nurs Sci Q. 2015;28(1):36-41.
17. Longo J. Bullying and the older nurse. J Nurs Manag. 2013;21(7):950-955.
18. Bowling NA, et al. Target personality and workplace victimization: A prospective analysis. Work Stress. 2010;24(2):140-158.
19. Lowenstein LF. Bullying in nursing and ways of dealing with it. Nurs Times. 2013;109(11):22-25.
20. Papa A. Field of dreams or toxic wasteland: How does your workplace measure up? Paper presented at the New Jersey Emergency Nurses Association Emergency Care Conference, Atlantic City, NJ, March 2011.
21. Bartholomew K. Healing RN-RN hostilities & creating healthy relationships. Paper presented at the Emergency Nurses Association Leadership Conference, Portland, OR, February 2011.
22. Leininger M. The tribes of nursing in the USA culture of nursing. J Transcult Nurs. 1994;6(1):18-22.
23. Leininger M. Transcultural nursing research to transform nursing education and practice: 40 years. J Nurs Sch. 1997;29(4):241-247.
24. Leininger M. Theoretical questions and concerns: Response from the Theory of Culture Care Diversity and Universality perspective. Nurs Sci Q. 2007;20(1):9-13.
25. Leininger MM. Leininger's theory of nursing: Cultural care diversity and universality. Nurs Sci Q. 1988;1(4):152-160.
26. Broome BS, Williams-Evans S. Bullying in a caring profession: Reasons, results, and recommendations. J Psychosoc Nurs Ment Health Serv. 2011;49(10):30-35.

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