September 21, 2021

Countering bullying through teamwork, increased awareness

Bullying is a serious problem seen in all aspects of life—at home, in school, and in the workplace. Anyone can be a bully, but bullying is often carried out by those who are threatened by or view themselves as superior to others. However, the younger generations, who are slowly taking over the job market, are adept at recognizing signs of bullying and quick to reject organizations that do not address or seek to correct it.

In the OR, bullying can harm nurses’ physical and psychological well-being. It can occur from and to any staff member, for example, from a physician to a nurse or a medical professional to a surgical technologist. The act of bullying can come from an individual or a group of people; but the type of bullying that occurs most often in the OR setting is peer to peer—a type of bullying also referred to as lateral violence. Educating OR staff on the patterns of bullying behavior is a step in the right direction, but establishing accountability and strategies for prevention are key to reducing or eliminating bullying in the workplace.

Vangie Dennis, MSN, RN, CNOR, CMLSO

“Our profession requires an environment in which patients, staff, colleagues, physicians, trainees, and all other individuals are treated with respect, civility, and tolerance,” says Vangie Dennis, MSN, RN, CNOR, CMLSO. Dennis, assistant vice president of perioperative services, AnMed Health, Anderson, South Carolina, adds that bullying is especially concerning in healthcare, where life and death decisions are made daily.

Dennis will share her insights on how she has worked to stop bullying at various institutions where she has worked at the annual OR Manager Conference in Chicago on October 22. Her session is titled “Hit from your blindside: #Stop bullying #Must do better.”


Bad acts add up

Individual acts of bullying can appear and may be considered harmless by many in the OR environment, says Dennis, but those acts can multiply if they are not checked. They can create a toxic environment that takes a toll on employee morale and job satisfaction.

“One of the biggest side effects of bullying is that it rattles people so badly that it can affect patient safety,” she says. Dennis adds that it is important to realize that bullying is not just throwing an instrument or cussing at someone. Paralanguage­—meaning aspects of communication that do not involve words (eg, use of body language, gestures, facial expressions, or tone) but that add emphasis or shade meaning—is also an integral part.

She gives the example of when she wrote up a surgical technologist, and he complained that he had not said anything wrong. Dennis explained to him that it was not what he said, but how he said it. “When communicating with one another, remember that 55% is our body language, 38% is our tone of voice, and only 7% is the words we say,” Dennis explains.

Sometimes bullying behavior is not easy to measure, so OR personnel must be trained to recognize the trends, says Dennis. This can be done with electronic variance reporting or safety reports. Once personnel start reporting incidents of bullying behavior, a trend should become visible.

“For example,” Dennis explains, “I report a surgeon for cussing at me, and he tells the CMO that it isn’t true. However, if there are six other reports from different people over a 6-month period in the electronic reporting system, it is harder for the surgeon to deny the behavior.”

Other signs of bullying in the OR that might be difficult to identify as bullying include:

• the charge nurse or director giving out unfair assignments

• gossiping in the break room

• backstabbing

• making jokes or slurs about a team member’s appearance or ethnicity

• withholding information that is needed to do an assignment.


Influence of generational traits

Generational traits in a workplace environment can also influence reactions of healthcare workers to bullying and inappropriate workplace behavior, and knowing these traits is important for maintaining a healthy culture.

“Inappropriate behavior can be learned and passed on,” says Dennis. “We can bring a behavior to the job from the generation in which we learned nursing. Traditionalists, who still make up about 2% of the workforce, will say, ‘I learned it the hard way, so you are going to have to learn it the same way.’”

Dennis gives another example of a generation Y (ie, millennial) surgical technologist who came into her office, sat down on the couch, and propped her legs up. “Though some managers might be mortified by this behavior,” she says, “it is important to understand that this is the cultural behavior of generation Y. They are very relaxed and very open.”

According to Dennis, millennials, who make up 35% of the work population, would rather leave a job than withstand bullying. “They do not mind starting over somewhere else. They will say: ‘I’m not putting up with the way she talks to me,’ and they will walk right out the door. My baby boomer generation would never do that. We would have just kept going and been thankful that we had a job,” she adds. Even now, baby boomers, who make up 25% of the work population, do not want to quit working. They believe in hard work and are workaholics by nature.

Most generation X workers, who make up 33% of the workforce, demonstrate a pattern of job hopping every 2 years or so. Their work ethic veers toward the entrepreneurial, and they value a nontoxic work environment over pure loyalty. Like millennials, they will leave if they do not like the way they are being treated.

“People sometimes ask me, ‘why invest in training generation X individuals if they are just going to leave in 2 years anyway?’” says Dennis. “But generation X workers will tell you that they want to learn, and the more they learn, the higher is the likelihood that they’ll stay.” Dennis notes that managers need to find a way to connect with this generation—“find out what they want and what will keep them engaged”—to better inspire loyalty. “They like to move up the ladder quickly,” she adds.

Generation Z workers already make up 5% of the work population. Some 40% of them want to interact with their bosses on a daily basis, and 84% expect their employers to provide them with formal training. They are tech savvy and value security and stability over risk, but they will turn down a job if diversity and inclusion are not prioritized at the organization. They are very familiar with bullying because of social media, and they will not tolerate it in their workplace. “We have to be authentic with them and emphasize practicality,” says Dennis.

“In the end,” she says, “if we don’t understand all of these different personalities and how they react, we will never be able to mesh them into a healthy workplace culture that fosters friendship and loyalty.” Dennis notes that another thing she has learned over the years is that when leaders are good to their subordinates, they will want to do more for them. This parallel motivation aligns everyone to work harder, cooperate, and be supportive of one another.


Increasing awareness of bullying

An update of The Joint Commission’s Sentinel Event Alert on “Behaviors that undermine a culture of safety,” from June 18, 2021, was key to increasing awareness of workplace bullying and its effects. In it, The Joint Commission identified intimidating and disruptive behaviors as a sentinel event and referred to bullying as the fostering of medical errors contributing to patient satisfaction and preventable adverse outcomes. (sidebar, The Joint Commission Sentinel Event Alert 40).

The Joint Commission Sentinel Event Alert 40: Behaviors that undermine a culture of safety

The Joint Commission issued the “Sentinel Event Alert 40: Behaviors that undermine a culture of safety,” on July 9, 2008, and updated it on June 18, 2021. In the Alert, The Joint Commission says that “intimidating and disruptive behaviors can:

• foster medical errors

• contribute to poor patient satisfaction and preventable adverse outcomes

• increase cost of care

• cause qualified clinicians, administrators, and managers to seek new positions in more professional environments.”

The Joint Commission describes intimidating and disruptive behaviors as:

• overt actions—verbal outbursts and physical threats

• passive activities—refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.

Both overt and passive behaviors undermine team effectiveness and can compromise patient safety, The Joint Commission notes.

That is why recognizing bullying behavior, from the most obvious expression to the most understated sign, is only the first step. To foster a work culture of inclusion and safety, managers also need to consider how to combat bullying. Some scenarios of bullying behavior and their solutions, proposed by Dennis based on real incidents, are:

Mob mentality: Several seasoned staff members were being passive-aggressive toward a nurse. They were discrediting her and making derogatory comments about her in front of surgeons, which made the surgeons question her clinical skills. When confronted, the staff members denied the accusations, and the behavior escalated until the nurse wanted to quit.

Proposed solution: Managers should meet individually with all staff members in question. Even if no specific accusations can be made, the behavior should be confronted to show that such actions are not tolerated. When bullying is brought to light, bullies rarely stand united and might start accusing and blaming each other. Direct after-action is also needed to drive the point home. In this case, managers should reiterate their behavioral expectations and ask all staff members to sign a no tolerance attestation form against lateral bullying or hazing.

Surgeon bullying staff: A surgeon began to discredit several staff members with personal attacks. The comments ranged from calling them incompetent or overweight, to bringing attention to their lower financial status and suggesting they were inferior because of it.

Proposed solution: Managers need to encourage staff members to write variance reports so that such incidences are tracked. They should also empower staff to voice when they are not comfortable with a situation. Giving victims of bullying some agency to combat the aggression can be an effective tool to keep it from escalating. If the situation does escalate, managers should give credence to the case by bringing it to the chief medical officer.

Manager-to-manager: At a health system with two campuses, the OR director at one campus bullied the OR director at the other. One director exhibited passive-aggressive behavior and made disparaging remarks about the other director in front of employees. Neither director liked the other, but only one was acting out.

Proposed solution: Higher-ups should step in and speak with these directors directly, both separately and together. Managers set the example, and they will only be fit to deal with bullying in their own teams if they can recognize and resolve it among themselves. Setting ground rules for communication and reinforcing the need to be respectful need to happen at the top.

Boss to manager: A boss was discrediting a manager by talking to the staff about her and looking for situations to discredit her integrity and work ethics. The boss’ goal was to terminate her with reason.

Proposed solution: Dennis notes that this is probably the most difficult bullying situation to handle—managers having to confront their bosses professionally about their behavior. The manager could look for another job, report the boss (which usually does not work), or escalate the situation to corporate compliance with hopes that there are other reports showing a trend of bad behavior. When organizations begin to implement variations of the other proposed solutions, escalating complaints will become the safer and most effective method to combat bullying.


Influence of the pandemic on bullying

Though strong collaboration, teamwork, and support emerged among front-line caregivers and clinical teams during the COVID-19 pandemic, inappropriate behaviors were still common, according to the June 7 Becker’s Hospital Review. Nursing executives from Geisinger—based in Danville, Pennsylvania—and Novant Health—based in Winston-Salem, North Carolina—noted that although the pandemic brought team members together, there were also inappropriate, unwanted behaviors that caused nurses distress.

Novant saw an increase in inappropriate behaviors such as name-calling by patients, visitors, and family members across all units, and these behaviors remain elevated in emergency departments and intensive care units. Lack of communication and limited visiting hours likely contributed to the uptick, say Novant’s leaders. At Geisinger, 72% of nurses experienced unprofessional behavior from a provider in the past year.

These behaviors were reported via a confidential phone line or email. Since this confidential reporting went into effect during the pandemic, there have been 40 reports, all of which were substantiated. Only 3% of the 40 came from nursing.

Geisinger and Novant identified five strategies to combat workplace bullying and harassment toward nurses or other staff, including:

• updating their definitions of workplace bullying and harassment,including wording specific to social media

• forming a multidisciplinary team to oversee anti-bullying initiatives, along with a committee to review and resolve reports of inappropriate or unprofessional behavior

• educating team members, leaders, and the public on what bullying looks like and how their organizations address it

• making reporting easier by setting up confidential channels that go to a small, core group of leaders

• investigating all reports and implementing coaching or disciplinary actions, along with tracking those who have repeat complaints lodged against them.

“Workplace bullying and lateral violence among nurses can heighten tension in an already high-stress environment,” says Dennis. “To create a more positive workplace environment, OR leaders must take the time to truly understand lateral violence and the significant adverse effects it can have on staff and their patients.”

To learn more about Dennis’ session on workplace bullying or to register for the OR Manager Conference, visit ✥



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