Have you ever had to work with one of those intimidating nurses who makes you feel about three inches tall? You know the type. This is the kind of nurse who sends messages with body language and tone that you are incompetent or that your questions are a waste of their time. This might be another staff nurse, a charge nurse, or even the nurse manager. These nurses may be known to everyone as a bully or they may single out less experienced nurses.
Like many entering the workforce, every nurse has had this experience at some point.
What is Lateral Violence?
Put simply, lateral violence is bullying. The American Nurses Association (ANA) defines bullying as “repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient." These actions include intimidating behavior, name-calling, making faces behind someone’s back, or threatening. But often, lateral violence is more covert. When a nurse or other team member routinely speaks to you with exaggerated impatience, refuses to answer valid questions, provides misinformation, sets you up to fail, uses condescending language, spreads rumors, or questions your judgment constantly (especially in front of others), this is bullying.
The ANA found that up to half of the nurses polled have been bullied at work, either by a peer (50 percent) or a person in a higher level of authority (42 percent).
Worker-on-worker violence is often directed at persons viewed as being "lower on the food chain" such as in a supervisor to supervisee or doctor to nurse though incidence of peer to peer violence is also common. - From Workplace Violence Prevention for Nurses from CDC and NIOSH.
How Does A Nurse Become a Bully?
Every student nurse I have known has said the same thing: “I will never be one of those nurses!” And yet, every one of “those nurses” was once a student or a new grad who probably dealt with a bully. When does that transformation happen? At what point does a nurse slip into bullying behaviors, and why?
My preceptor rolled her eyes and looked at me like I was stupid every time I asked her a question. I finally stopped asking. Doesn’t she realize I’ve only been a nurse for 3 weeks? - From Break the Bullying Cycle
One of the theories about lateral violence is that it happens when nurses feel disempowered or experience burn-out. Nurses have a lot of responsibilities in the hospital, but they may perceive themselves as having less power or authority than the physicians or hospital administrators. Nurses can feel compelled to work double shifts or take unscheduled call shifts, accept extra patients, and stay after the end of the workday to complete their charting. Nurses may skip meals to care for their patients and wait to use the restroom themselves while they toilet their clients. Nurses also face aggression from the very patients they care for: Up to a quarter of nurses have been physically assaulted at work by a patient or a patient’s family member, according to a recent ANA survey of 3,765 RNs.
"In many healthcare facilities, administrative hierarchies promote and perpetuate oppressive conditions, such as the inability to take uninterrupted breaks or meals, inadequate staffing ratios, limited supplies, and little recognition of nurses’ ability to think critically. These conditions contribute to the problem (Townsend, 2012)."
In human groups of unequal power, the dominant group exerts so much pressure downward that the oppressed group cannot direct its power upward— so they unconsciously attach to each other. - From A Voice From The Frontlines: Bullying And Medical Error
Due to fear of judgment or retribution from management or administration, many nurses just "suck it up." Instead of directing their frustrations at those in authority, nurses may act out against someone safer – a peer. This may be subconscious or deliberate, but it is usually not "about" the target at all. As with schoolyard bullies, lateral violence is often misdirected anger, sadness, or fear, and acted upon by those who feel they have no better outlet. In nursing, these misdirected feelings are often aimed at the person least likely to strike back: a new colleague, recent graduate, or student nurse.
When this behavior goes unchecked, it becomes part of the culture–just the way it is. "Nurses eat their young" You may hear this early along your clinical journey–as if acknowledgment of the problem somehow makes it acceptable. But bullying is not acceptable.
How Bullying Affects Nurses
The targets of bullying suffer from symptoms of anxiety and stress. They may experience social anxiety and even hypervigilance as they seek to avoid further aggravation of the aggressor. Avoidance and withdrawal behaviors are common. In some instances, bullying contributes toward a nurse’s decision to leave his or her position or even the profession of nursing.
Other symptoms of psychological distress symptoms reported across studies have included anxiety, irritability, panic attacks, tearfulness, depression, loss of confidence and self-esteem, headaches, loss of sleep, stomach upset, and suicidal ideation (Vessey, DeMarco, & DiFazio, 2010).
Nurses say it is sometimes easier to heal from the physical injuries than from the guilt, fear, and anxiety that persists long after the event. Witnesses to workplace violence may feel shocked, feeling a sense of disbelief or unreality about the situation, as well as fear of future event and psychological numbing (CDC, 2015). Witnesses who report bullying often fear retaliation and a reputation as a "tattletale" -- fears that may shield a bully from discipline.
Beyond the immediate trauma, negative outcomes may also include low morale and productivity that result from lack of trust in management, loss of team cohesiveness, and a sense that the work environment is hostile and dangerous. Workplace violence may also result in increased job stress, absenteeism, family turmoil, and worker turnover. - From Workplace Violence Prevention for Nurses from CDC and NIOSH.
Roughly 60% of new graduate nurses who are bullied quit their job within 6 months. One in three of them considers leaving the profession altogether after these abusive or humiliating encounters. High nurse turnover jeopardizes health care and results in nurses who may lack the experience necessary to recognize and act quickly on potential patient problems (Townsend, 2012).
Disrespectful behavior and intimidation undermine the confidence of nurses, which also negatively affects their ability to provide the best care for their patients. Bullying behavior interrupts communication within the care team, jeopardizing the exchange of critical information for collaborative decision-making, both of which are associated with increased medical errors and worse patient outcomes (Vessey, DeMarco, & DiFazio, 2010).
How Bullying Affects Our Clients
Bullying isn’t only a problem for other nurses. I’m sure you can recall a time you have hesitated to approach “that nurse” about a patient concern. Perhaps you have delayed asking for information or help because you knew the request would be met with an exaggerated sigh or a comment meant to make you look inadequate to nearby staff. Nurses who’ve been bullied feel isolated from coworkers; they may be reluctant to ask questions and afraid to speak up to advocate for their patients.
Lateral violence in nursing jeopardizes the communication of critical information and collaborative decision-making, increasing medical errors, and leading to poorer patient outcomes (Vessey et al., 2010). In a 2008 Sentinel Alert that addressed disruptive behaviors, The Joint Commission noted that “intimidating and disruptive behaviors can foster medical errors and (lead) to preventable adverse outcomes.”
An Institute for Safe Medication Practices survey showed that 49% of respondents had altered the way they handled a medication order or clarification because of intimidation. The survey also showed that 17% of respondents had felt pressured to accept a medication order despite concerns about its safety on at least three occasions in the previous year; 13% had refrained from contacting a prescriber to clarify an order on at least 10 occasions; 7% said that in the previous year they had been involved in a medication error where intimidation played a part.
What To Do If You Are the Target of a Bully
On the first occurrence, tell the bully directly that you find his or her behavior offensive and unacceptable. Some bullies don’t recognize that their behavior is abusive, and they need a reality check. You may need to make it clear that you’ll notify a manager if the behavior continues. Sometimes this is all that is required to stop the unacceptable behavior.
If you are being spoken to unprofessionally, you may consider simply walking away. "When you walk away from a bully attack, you take the audience away with you. Seldom will a bully continue screaming, yelling, or criticizing without an audience" (Thompson, 2013).
From Stop Nurse Bullies in Their Tracks, by Renee Thompson, MSN, RN, CMSRN, here are sample situations and possible responses:
- Yelling and screaming: Interrupt and say, “I’ll be willing to continue the conversation when you are not yelling.” If the yelling continues, walk away.
- Openly criticizing: Interrupt and say, “I’ll be receptive to your feedback when you deliver it calmly and respectfully.” If the bully continues to criticize, walk away.
- Openly minimizing accomplishments: “I respect your decisions regarding education and I expect you to respect mine.” If the bully continues, walk away.
- Name the bullying behavior: For example, if you say to a bully, “You always give me the worst assignments,” the bully can deny the charge. If you say, “For three shifts in a row, I’ve been assigned four patients while the other nurses on my shift have been assigned only three,” it’s hard for the bully to deny this fact.
- Additional examples of naming both covert and overt behavior: “You are yelling and screaming at me in front of patients and their families.” “This morning during the staff meeting, when our manager acknowledged my recent BSN achievement, I heard you snicker and saw you roll your eyes.” “I’ll be willing to talk about my mistake when you are ready to speak privately rather than calling me a baby in the middle of the unit.”
- Above all, don't stoop to that level. Model the behavior you expect in return by showing respect. Share the facts in a straight-forward manner and avoid labeling. Connect your concerns to how it affects you and patient care.
First, you need to recognize that a bully’s abuse consists of lies to try to break you down. Thus, surviving the bully’s terrorism depends on maintaining your self-confidence. Everyday, remind yourself that you are a good person. Make a habit of focusing on your accomplishments, instead of what went wrong. Doing so helps keep your self-confidence intact. This doesn’t mean you should avoid constructive criticism. Just don’t make it your main focus. - From How to Survive a Bully
Hospitals or individual units can adopt a code word or gesture that staff can use to alert others in the moment. Staff must be taught how to respond when the code is employed, by interrupting the situation or offering assistance. The code can prompt others to intervene and stop the inappropriate behavior (from stopbullyingtoolkit.org).
If all else fails, you may need to avoid contact with the bully. This can be as simple as not being alone with the bully or it may be as difficult as changing shifts or changing positions (Mladineo, 2006).
If the situation is a chronic one, you must begin documenting each specific occurrence. Note the date and time of the situation, the behavior or action that occurred, any witnesses, and the impact on you and your productivity. Be as objective as possible, and document any effect on the situation may have had on patient care. Provide a copy of these reports to the nurse manager. If you don't get anywhere, you may need to reach out to Human Resources or even the Chief Nursing Officer.
We Are All Responsible for a "Zero Tolerance" Culture
Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team. All intimidating and disruptive behaviors are unprofessional and should not be tolerated. - Joint Commision Sentinel Event Alert, 2008
The problem of lateral violence is perpetuated by normalization of these behaviors in a health care culture that ignores it, even when those acts are witnessed. ANA’s recommendation is that that RNs commit to “promoting healthy interpersonal relationships” and become “cognizant of their own interactions, including actions taken and not taken.”
“Knowing what’s right doesn’t mean much unless you do what’s right.”–Theodore Roosevelt
Nurse managers have an important role in creating a new culture. They should encourage staff to report bullying incidents and ensure that those who experience or report abusive incidents remain safe from retribution. Actions should be taken to "discipline bullies, counsel victims, and implement corrective measures to prevent recurrence" (Townsend, 2012). Instituting a zero-tolerance policy sends a clear message to all staff that every incidence of lateral violence will be taken seriously. Facility policies should clearly define what acts are unacceptable and what consequences will ensue if the policy is broken.
Treating all members of the healthcare team with respect leads to collaboration, open communication, and teamwork and promotes delivery of the high-quality care we all strive for. We can break the cycle of bullying and abuse through individual accountability, a mentoring culture, and support for our nursing peers (Townsend, 2012).
The most important thing you can do to change the culture of bullying is to refuse to engage in it or accept it. Don’t take part or encourage other nurses when they criticize or give a colleague a hard time. Bullying will not be an accepted part of the health care culture if it is not accepted by nurses. Be a part of a new culture by leading the way as a role model for our “caring profession.”
For more information:
StopBullying.gov General prevention information and resources including a hotline and info on cyberbullying
CDC's Workplace Violence Prevention for Nurses - A free online course, including skills for preventing and responding to workplace violence
How to Respond to Nurse Bullying Behavior: 3 Powerful Scripts - Video from Renee Thompson, RN, MSN, CMSRN
Nurse Bullying Q & A: Dealing with an Overt Bully - Video from Renee Thompson, RN, MSN, CMSRN
Two Minute Tips for Nurses: Bullying - Video from Renee Thompson, RN, MSN, CMSRN
The Hard Truth: Bullying and Workplace Violence in Healthcare - a short video from ANA