Creating a Safe Space: Preventing Bullying and Violence Among Oncology Nurses

Three years ago, LaToya Lewis, EdD-CI, MSN, RN, and her colleagues embarked on a study to evaluate horizontal violence and bullying among nurses who work in oncology inpatient units and outpatient services at an academic medical center in South Florida.

LaToya Lewis, EdD-CI, MSN, RN

Although bullying and incivility in nursing are not new issues, they are a pervasive problem. A 2017 survey found that 45% of nurses had been verbally harassed or bullied by other nurses, and 41% had been bullied by managers or administrators. And although previous studies have examined how bullying affects all nurse specialties, Lewis, an assistant professor of clinical at the University of Miami School of Nursing and Health Studies in Florida, and her colleagues specifically looked at how bullying affected oncology nurses.

“Through our survey, we found that bullying was more prevalent in the outpatient oncology clinic, although nurses who worked in both inpatient and outpatient settings experienced conflict,” Lewis said.

Many of the nurses surveyed experienced horizontal or lateral violence, which Lewis described as nonphysical, hostile, aggressive, or harmful behavior toward a coworker.

“Horizontal violence is characterized by emotional, verbal, and defiant behaviors such as snide remarks, public humiliation, talking down to a colleague, mocking, harassment, and intimidation,” Lewis said. “Physical violence can involve pushing, grabbing, or invading a coworker’s physical space.”

All forms of workplace bullying can take their toll on nurses and lead to reduced self-esteem, anxiety, depression, and even physical symptoms such as insomnia and gastrointestinal issues.

“Many nurses reported feeling hesitant to report the bullying because they thought it would only make the situation worse,” Lewis explained. “The effects of horizontal violence and bullying not only negatively impact a nurse’s professional quality of life, they also affect nursing retention and employee and patient satisfaction.”

When the survey was completed, Lewis and her colleagues reported the findings to hospital administrators, who were surprised by the results.

“The administration believed they had a zero tolerance for workplace bullying, and they weren’t aware of some of the incidents,” Lewis said. “Many nurses suffered in silence rather than voice their concerns because they had seen others report horizontal violence, only to have the problems persist.”

As a result, the medical center began incorporating education about appropriate professional behaviors that are consistent with the hospital’s code of conduct into orientations for new hires, Lewis said. Administrators also worked to engage midlevel nurses and other oncology staff to advocate for a culture of kindness and civility.

“In addition to establishing programs that promote awareness and discuss how to address workplace bullying, the medical center also put a renewed emphasis on positive behavior and the contributions of their nursing staff through programs such as the DAISY Foundation awards,” Lewis said. “Nursing leaders can create a positive work environment that serves to thwart workplace bullying.”

Addressing Bullying and Finding Solutions

Judith Vessey, PhD, MBA, FAAN, the Lelia Holden Carroll Professor in Nursing at Boston College’s Connell School of Nursing in Massachusetts, also has conducted research on horizontal violence and bullying among nurses.

Judith Vessey, PhD, MBA, FAAN

In her study “Bullying of Staff Registered Nurses in the Workplace,”³ which was published in 2009, Vessey and her colleagues found that perpetrators of workplace bullying included senior nurses, charge nurses,
nurse managers, and physicians who publicly humiliated, isolated, excluded, or excessively criticized staff nurses. According to Vessey, stress levels were reported as moderate to severe among nurses. The lack of an
available workplace solution meant that support was found primarily among family, colleagues, and friends.

“It’s important to begin by looking at what’s happening at the unit level, how good is the leadership, and [whether] nurses see themselves as part of a team and have a sense of psychological safety,” Vessey said. “Unfortunately, some nurses work in an unhealthy environment where they don’t feel safe speaking up.”

Vessey explained that psychological safety is when an employee can speak up without risking embarrassment, humiliation, or punishment.

“Psychological safety creates a climate where nurses can do their best work,” Vessey said. “Without psychological safety, a nurse who is being bullied won’t come forward and the bad behavior will continue.”

Over time, Vessey says workplace incivility and bullying can lead to low employee morale, increased absenteeism, and high turnover.

“It’s important to create an environment where nurses want to work and incivility and horizontal violence are not tolerated,” Vessey says. “Unit-based leaders may be aware of bullying but unsure how to address it. These leaders can start by creating opportunities for dialogue between staff members and encouraging staff feedback.”

In addition to being patient advocates, nurses also need to master being advocates for their colleagues and for themselves. Conflict resolution training can teach nurses the skills they need to diffuse workplace bullying scenarios, whereas nurse mentorship programs can foster teamwork, combat bullying, and increase retention among nurses who are just beginning their careers in oncology. 

When Patients and Families Become Violent

In addition to cases of horizontal violence among nurses, cases of workplace violence involving patients and family members are also on the rise. In November 2020, National Nurses United surveyed 15,000 registered nurses around the country and found that 20% reported an increase in workplace violence. Among the reasons for the increase, the survey results showed, were decreased staffing levels, visitor restrictions, and mandatory masking.

Typically, nurses are not taught how to handle violence while in nursing school, but, fortunately, there are many free resources available to help nurses learn how to safeguard themselves.

The Crisis Prevention Institute offers programs in nonviolent crisis intervention, verbal intervention, dementia care, conflict prevention techniques, and more. Available online courses teach important deescalation techniques and risk assessment.

The Occupational Safety and Health Administration (OSHA) has published a guidebook for nurses and other health professionals who want to learn strategies for preventing workplace violence.

National Nurses United is offering an online class: “Violence on the Job: Prevention and Advocacy for Nurses.” The hourlong class is free during the pandemic. The 1 continuing-education unit course discusses effective workplace violence prevention measures and how nurses can advocate for violence prevention at their workplace.

The Centers for Disease Control and Prevention offers “Workplace Violence Prevention for Nurses,” a free interactive online course that illustrates how to recognize warning signs of violence in individuals, how to implement a workplace violence prevention program, and more.

The American Nurses Association (ANA) has a free downloadable #EndNurseAbuse resource guide that encourages nurses to send an email to their legislators to end violence against nurses, shows how to report all abuses, and offers strategies nurses can use to protect themselves on the job.

At this time, the ANA notes that OSHA doesn’t require employers to implement workplace violence prevention programs, but it provides voluntary guidelines and may cite employers for failing to provide a workplace free from recognized serious hazards. The ANA notes that many states have laws designating penalties for assaults that include nurses and other health professionals.

In addition, the American Association of Critical Care Nurses has a free downloadable guide, “Standards for Establishing and Sustaining Healthy Work Environments,” which discusses skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.

Bassett Healthcare Network in New York has given nurses and other staff a wearable emergency alert system that allows them to discreetly call coworkers or security in the event of an emergency. The Strongline Staff Safety System uses Bluetooth technology and attaches to a nurse’s badge.

All nurses should feel safe in their workplace and have the tools and support needed to combat bullying, violence, incivility, and toxic environments.

References:

1. Lewis-Pierre, L., Anglade, D., Saber, D., Gattamorta, K., & Piehl, D. (2019). Evaluating horizontal violence and bullying in the nursing workforce of an oncology academic medical center,Journal of Nursing Management, 27(5), 1005-1010.

2. RN Network, Portrait of a Modern Nurse Survey Finds Half of Nurses Consider Leaving the Profession, RNNetwork.com (accessed July 2021).

3. Vessey, J., DeMarco, Rosanna. Gaffney, Donna, Budin, Wendy (2009).Bullying of staff registered nurses in the workplace: a preliminary study for developing personal and organizational strategies for the transformation of hostile to healthy workplace environment, Journal of Professional Nursing, Sep-Oct 2009;25(5):299-306.

4. National Nurses United, National Nurse Survey Exposes Hospitals’ Knowing Failure to Prepare for a COVID-19 Surge During Flu Season, nationalnursesunited.org (accessed July 2021).