Workplace Abuse in Nursing

Policy Strategies

Jane H. Barnsteiner

“Organizations learn and evolve through conscious, deliberate action. Deliberate action is ethical. When the time to act has come, it is unethical not to do something.”

—David Thomas, ethicist

A culture of safety is necessary to achieve continuous and sustainable changes that promote patient safety and employee satisfaction in an organization. Bullying, harassment, and “disruptive behaviors” constitute workplace abuse and violate the principles of a culture of safety, endanger patients, and are a cause of employee dissatisfaction and turnover (The Joint Commission, 2008). Workplace abuse must be managed with a multifaceted approach that includes engaging top leadership, setting expectations, training and progressive discipline, and self-management.

Workplace abuse is an all too common experience in health care settings. More than 70% of physicians and nurses report that they have witnessed such disruptive behaviors (Rosenstein, 2002). Further, fewer than 10% of supervisors are reported to address issues of abuse in the workplace (AACN, 2005). A number of terms are used to describe workplace abuse and include disruptive behavior, bullying, and lateral violence. While the definition of each of these is slightly different, for the purposes of this chapter all are considered workplace abuse.

What Constitutes Workplace Abuse?

Workplace abuse is behavior that interferes with the ability of employees to provide safe and effective care, undermines the confidence of team members to effectively care for patients, and causes a concern for physical safety and/or undermines effective teamwork. Overt and passive activities meant to intimidate or disrupt care may be from peer to peer, physician to nurse, or supervisor to employee. While there is increasing concern related to abuse from patients and family members, this is not included as a focus of this chapter.

Workplace abuse may take a number of forms, including profane or disrespectful behavior; name calling; demeaning behavior; sexual comments or innuendos; racial or ethnic jokes; outbursts of anger; criticizing in front of patients or other staff; throwing objects; intimidation that suppresses input from other providers; and retaliation against clinicians who raise concerns about safety, conduct, or culture issues. It also includes a preceptor being visibly exasperated when asked a question by an orientee, gossip about co-workers, scapegoating, public verbal outbursts, refusal to answer questions or phone calls, intimidating body language, or physical violence.

Workplace abuse has a negative effect on the quality of patient care (Barnsteiner, Madigan, & Spray, 2001; Institute for Safe Medication Practices (ISMP), 2004; Johnson, 2009; Rosenstein & O’Daniel, 2005). This may result from a reluctance to ask questions related to patient care or workarounds because staff may avoid those known to be abusive. Examples include an RN not notifying an MD of a change in patient status, keeping silent about a safety concern rather than questioning a known disruptor, administering a medication despite serious unresolved safety concerns, or tolerating substandard care such as no hand washing or surgical site marking. It may affect work productivity by causing rework or delays in care. Public and private policies have been developed to reduce abuse among health care workers. These policies can and should be extended to the local work unit where the abuse takes place.

Incidence

Reports vary on the incidence of workplace abuse. Rosenstein (2002) reported that 96% of nurses have witnessed workplace abuse. Diaz and McMillin (1991) reported that 64% of nurses have experienced disruptive behaviors, and 23% of nurses reported that something has been thrown at them. In a survey of nursing staff in a prominent children’s hospital, 65% reported they had experienced verbal abuse by physicians in the past year, and 24% reported they had felt afraid while at work (Barnsteiner, Madigan, & Spray, 2001). Further, 97% of respondents in the survey stated that hospital leadership should be involved in solving issues of workplace abuse.

The American Association of Critical-Care Nurses collaborated on a large national survey that examined the challenges related to healthy work environments, one of which was workplace abuse (Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005). Seventy-seven percent (77%) of respondents indicated that they work with someone who is condescending, insulting, or rude; 33% reported that they work with someone who is verbally abusive; and 52% work with clinicians who abuse their authority by pulling rank, bullying, and forcing their point of view on them. Only 2% of non-supervisors and 5% of supervisors confronted issues related to disrespect and abuse.

Causes

Various causes of workplace abuse have been postulated. Workplace abuse arises from individual and systemic factors (Johnson, 2009; The Joint Commission, 2008). There continues to be a steep power gradient among professionals, particularly between physicians and nurses. Fear of retaliation, lack of formal systems to report or address, and the high pressure and emotionality of the practice setting are contributing factors. Individuals who are abusive may be fatigued or immature, or may lack interpersonal or conflict-management skills. What is clear is that the behavior has been tolerated, and there has been a leadership indifference to workplace abuse in health care.

Indicators of Workplace Abuse

Workplace abuse affects job satisfaction and retention. It is reported as the largest factor in job satisfaction for nurses. Rosenstein and O’Daniel (2005) reported that more than 30% of nurses knew at least one nurse who left because of workplace abuse. But we’ve known that abuse affects staff retention. In 1987, Cox reported that 18% of turnover could be attributed to workplace abuse.

A high rate of staff turnover is just one of a number of indicators that abuse is occurring in a workplace. Low ratings of overall job satisfaction—particularly of physician-nurse relationships, peer relationships, and relationships between staff and nurse managers—are all signs that workplace abuse may be a problem. The presence of cliques in a work area and reports of dueling units or shifts are also indicators (Alspach, 2008; Gilmore & Hamlin, 2003).

Work Environment and Errors

There have been numerous studies demonstrating the association between work environment and patient errors and the influence on job satisfaction and retention. In a study of more than 2000 health care professionals queried about workplace intimidation related to medication practices, 7% of respondents indicated that they were involved in a medication error during the past year in which intimidation played a role (ISMP, 2004). More than 45% of respondents in the ISMP survey indicated that past intimidating experiences caused them to not clarify medication orders or ask questions. Rosenstein and O’Daniel (2005) reported in a large survey of nurses that 17% of respondents were aware of a specific adverse event that occurred as a result of disruptive behavior.

There is an assumption that most health care workplace abuse is by physicians. A national sample survey of nurses who were victims of abuse said that intraprofessional abuse was commonplace (Vessey et al., 2009). Senior nurses, charge nurses, and nurse managers were identified as perpetrators of abuse. More than 50% of the respondents reported that they left their positions to take a new one after being abused. In a study of emergency nurses, 27% stated that they had experienced bullying in the previous 6 months, and there was a significant association of workplace abuse with intent to leave one’s current position (Johnson, 2009; Rosenstein & O’Daniel, 2005).

Communication and Healthy Work Environments

Communication is a significant factor associated with workplace abuse. Rosenstein and O’Daniel (2008) reported that one in three nurses stated that they have difficulty speaking up when witnessing patient problems due to fear and intimidation. One common theme in the literature is the need to improve communication skills and for all health care workers to become skilled in negotiation and conflict resolution. Nurses need to become as proficient in communication skills as they are in clinical skills. When abuse is present, a dysfunctional cycle can evolve. Poor communication may lead to frustration and workplace abuse; conversely, workplace abuse leads to poor communication as staff wish to have as little contact as possible with an abuser. The Joint Commission analysis of sentinel events ranks poor communication the number-one factor following root cause analysis of events causing serious injury.

Facilitating teamwork and collaboration has been demonstrated to improve communication among health care providers. Components of teamwork include positive communication, intraprofessional and interprofessional collaboration, valuing each member of the health care team’s contribution, active work to resolve conflict, and development of work-related shared vision and goals.