Your Young Are No Longer on the Menu: Having Zero Tolerance for Workplace Incivility and Nurse Bullying

Laura M. Cascella, MA, CPHRM

Much has been studied and written about workplace incivility and nurse bullying in healthcare, including the need for organizations to confront these issues in the pursuit of creating highly reliable and psychologically safe environments. Yet, these issues still are pervasive and often are considered intrinsic in the nursing profession, as evidenced by the well-known saying “nurses eat their young.”

Perhaps now more than ever, the urgency of addressing bad behavior in healthcare is critical. COVID-19 has exacerbated already-existing problems with burnout, absenteeism, and staff turnover and shortages. Despite uplifting stories about the perseverance and resilience of healthcare workers in the face of disaster, the emotional and physical toll of the pandemic on these individuals is immeasurable.

Even prior to the pandemic, experts were forecasting workforce shortages due to the aging population and their increasingly complex healthcare needs, the large number of healthcare providers expected to retire in the coming decades, and declining funding and faculty for education and training.¹

With the industry already facing these issues — as well as the aftermath of COVID-19 — healthcare organizations cannot afford to lose qualified providers to toxic or apathetic cultures that allow incivility and bullying to endure. This article answers key questions about workplace incivility and nurse bullying and offers strategies to help healthcare organizations reinforce a physically and psychologically safe culture that promotes dignity, fairness, and respect.

What Are Incivility and Bullying?

Incivility refers to rude, disrespectful, inconsiderate, or unacceptable behaviors and actions. These behaviors and actions can be verbal or physical, and they can be overt (e.g., screaming) or covert (e.g., refusing to speak to a team member). Incivility is not always targeted at a specific person, nor is it always intended to be harmful; however, it can create a hostile or toxic work environment, wreak havoc on staff morale, and jeopardize the quality of patient care.

Conversely, bullying is targeted at an individual or group of individuals with the intent to harm. The American Nurses Association (ANA) defines bullying as “repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient.”² Like incivility, bullying can be overt or covert, and some examples include hostile remarks, insults, threats, intimidation, rumors and gossip, withholding information, micromanaging, exclusion, sabotage, and micro-aggressions (common and subtle behaviors or actions that are biased or discriminatory toward a marginalized population).³

Who Are the Perpetrators and Victims?

Despite the well-known idiom noted earlier, workplace incivility and nurse bullying do not only affect young and/or new nurses. These issues are far-reaching and can affect individuals of any age, gender, or background. Incivility and bullying occur across the healthcare spectrum in all care settings, including academic and executive settings.⁴

Much like childhood bullies, the perpetrators of nurse bullying often have low self-confidence and use bullying behaviors to exert control and authority. They may have been victims of bullying themselves, and now are perpetuating that behavior as a defense mechanism. Their victims might be individuals who they view as weak or lacking support, or they might be individuals whom the perpetrator finds threatening in some way (e.g., more experienced, more accomplished, or more attractive).⁵

Personality traits, disorders, and other personal circumstances might also trigger inappropriate actions or behaviors that result in incivility or bullying. Examples include psychiatric conditions, personality disorders, and substance abuse problems.

Why Does Workplace Incivility and Nurse Bullying Happen?

Workplace incivility and nurse bullying can be attributed to various factors. Experts have suggested that broad issues might set the stage for incivility and bullying, such as poor intra-gender relationships, underrepresentation in roles of authority, power differentials, disrespect for the nursing profession, hierarchical issues, and inadequate training.⁶

A more direct factor is workplace culture, which plays a critical role in either enabling or stamping out disruptive and harmful behaviors. Organizations that lack or don’t enforce physical and psychological safety are fertile grounds for incivility and bullying, particularly if organizational leaders model these poor behaviors in their management style.⁷

Further, the very nature of the nursing profession can perpetuate toxicity. Nurses often work long hours under high-pressure circumstances. They shoulder a great amount of responsibility but often have little autonomy or decision-making power. When combined with other issues that plague healthcare — such as inadequate staffing, excessive workloads, poor oversight, role conflicts, and violence — the end result of incivility and bullying is not surprising.⁸

How Does Workplace Incivility and Nurse Bullying Affect Healthcare Organizations?

Workplace incivility and nurse bullying in healthcare can have far-reaching and extremely detrimental consequences. On the individual level, the person being bullied might experience physical and psychological effects, such as headaches, sleep disorders, gastrointestinal issues, anxiety, depression, poor quality of life, diminishing self-confidence, poor relationships, and even suicidal thoughts and actions.⁹

Individual symptoms and outcomes can cascade into systemic issues across organizations, such as burnout, lack of productivity, low morale, absenteeism, and staff turnover. In turn, these issues may lead to lower quality of care for patients, an increased risk of errors and oversights, deteriorating levels of patient satisfaction, and an increase in liability risks. The organization’s reputation also might suffer as a result of these snowballing issues, which can erode patient trust, hinder recruiting efforts, and ultimately affect market share.

The impact of workplace incivility and nurse bullying also can be very costly for healthcare organizations. Although the exact costs related to loss of productivity and other issues associated with incivility and bullying are hard to determine, estimates suggest they may cost U.S. healthcare organizations slightly more than $11,500 per nurse per year. Further, “The costs of incivility increase when one takes into account the expenses associated with supervising the uncivil employee; managing the situation; consulting with attorneys; interviewing witnesses; and recruiting, hiring, and training new employees.”¹⁰ Staff turnover is even more costly, with the rate of replacing a nurse estimated between $27,000 and $103,000.¹¹

How Can Healthcare Organizations Address Workplace Incivility and Nurse Bullying?

When it comes to workplace incivility and nurse bullying, simply discouraging it (or ignoring it) won’t solve the problem or lessen its fallout. “Addressing the problem requires total commitment at every point in the health care ecosystem, from the individual level to the organizational, including policy and advocacy for prevention.”¹² The following strategies can help healthcare organizations confront and prevent workplace incivility and bullying:

• Review your organization’s code of conduct and anti-harassment policies to ensure they specifically address workplace incivility and bullying. The code of conduct should explicitly state the organization’s zero-tolerance policy and define unacceptable and detrimental behaviors and their potential consequences.
• Ensure the code of conduct and associated policies are clearly communicated to all healthcare providers and staff members, and ask them to acknowledge the organization’s expectations for professionalism, respect, and dignity in the workplace.
• Make sure your organization's social media policies also prohibit incivility and bullying. As an article in Nursing Administration Quarterly notes, “The ease and immediacy of digital media—and the fact that it extends communication beyond the workplace—magnifies the impact of negative behaviors.”¹³
• Seek executive and leadership support for the organization’s code of conduct and zero-tolerance policy for incivility and bullying as well as support for early intervention when incidents occur. Provide leaders with training on communication, psychological safety, and team-building so that they model behaviors consistent with a respectful workplace.
• Educate providers and staff members about incivility and bullying, including the types of behaviors involved, the effect on individuals and the organization, and how they can seek support.
• Solicit staff feedback on your organization’s cultural climate though periodic surveys, discussion forums, team meetings, etc. Make sure a mechanism is in place that allows staff members to provide anonymous feedback.
• Establish reliable, consistent processes for reporting, investigating, documenting, and following up on allegations of incivility and bullying. Make sure employees know their concerns will be taken seriously, and foster a nonpunitive environment in which individuals feel comfortable reporting inappropriate behaviors.
• Make sure processes related to reporting, investigating, documenting, and following up on allegations of incivility and bullying are transparent. Everyone involved should know how the situation will be handled and the timeframe for each step.
• Call out bullying behavior and encourage bystanders (e.g., other nurses) to do so as well. As a recent article on nurse bullying notes, “The first step to changing something is to recognize it and put the right label on it.”¹⁴
• Consider some of the external factors that can contribute to bullying (e.g., work overload, long hours, power differentials, etc.), and determine whether your organization can make changes to eliminate these issues or lessen their impact.
• Identify resources to help individuals who have been bullied (e.g., behavioral health services or an employee assistance program), and to help individuals whose inappropriate behaviors might be the result of a behavioral health disorder or substance abuse issue.
• Empower nurses to work together to identify ways to improve the work environment and address issues that lead to incivility and bullying. Offer training on topics such as effective communication, diversity and inclusiveness, and conflict negotiation and resolution.¹⁵

In Summary

Incivility and nurse bullying are toxic and destructive, yet they continue to permeate workplace culture in all types of healthcare settings. These behaviors are so common and deep-rooted that they often are considered ingrained in the practice of nursing. When incivility and bullying go unchecked, the consequences can take a significant toll on individuals and organizations. Healthcare organizations should adopt zero-tolerance policies for these harmful behaviors and commit to a top-down, organization-wide approach that advocates for employee well-being and a strong culture of safety.

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¹ Edmonson, C., & Zelonka, C. (2019). Our own worst enemies: The nurse bullying epidemic. Nursing Administration Quarterly, 43(3), 274–279. doi: 10.1097/NAQ.0000000000000353

² Professional Issues Panel on Incivility, Bullying, and Workplace Violence. (2015). American Nurses Association position statement on incivility, bullying, and workplace violence. American Nurses Association. Retrieved from www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/incivility-bullying-and-workplace-violence/

³ Ibid; Edmonson, et al., Our own worst enemies: The nurse bullying epidemic.

⁴ Edmonson, et al., Our own worst enemies: The nurse bullying epidemic.

⁵ Ibid; The Joint Commission. (2021, updated). Quick Safety 24: Bullying has no place in health care. Retrieved from www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-24-bullying-has-no-place-in-health-care/bullying-has-no-place-in-health-care/

⁶ Dillon, S. (2021, January 7). Workplace bullying in nursing: Why it happens and how to confront it. Bravado Health. Retrieved from www.bravadohealth.com/2021/01/07/confronting-nurse-bullying/

⁷ Edmonson, et al., Our own worst enemies: The nurse bullying epidemic.

⁸ Ibid; The Joint Commission, Quick Safety 24: Bullying has no place in health care.

⁹ Professional Issues Panel on Incivility, Bullying, and Workplace Violence, American Nurses Association position statement on incivility, bullying, and workplace violence; Edmonson, et al., Our own worst enemies: The nurse bullying epidemic.

¹⁰ Professional Issues Panel on Incivility, Bullying, and Workplace Violence, American Nurses Association position statement on incivility, bullying, and workplace violence.

¹¹ The Joint Commission, Quick Safety 24: Bullying has no place in health care.

¹² Edmonson, et al., Our own worst enemies: The nurse bullying epidemic.

¹³ Ibid.

¹⁴ Dillon, Workplace bullying in nursing: Why it happens and how to confront it.

¹⁵ Professional Issues Panel on Incivility, Bullying, and Workplace Violence, American Nurses Association position statement on incivility, bullying, and workplace violence; Edmonson, et al., Our own worst enemies: The nurse bullying epidemic; The Joint Commission, Quick Safety 24: Bullying has no place in health care; Dillon, Workplace bullying in nursing: Why it happens and how to confront it; American Association of Post-Acute Care Nursing. (2021, February 23). Why nurses eat their young and how to stop this damaging practice. Retrieved from www.aapacn.org/article/why-nurses-eat-their-young-and-how-to-stop-this-damaging-practice/

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