Among perioperative nurses, they are sometimes referred to as the “killer B’s”: burnout and bullying. Both of these B’s have resulted in added stress, job frustration, dissatisfaction and sleepless nights for many OR nurses.

In fact, bullying and burnout are inextricably linked – because bullying can be a major factor leading to burnout. Given this, it’s critical that health care organizations and nurse managers do everything they can to reduce instances of bullying in order to help reduce levels of burnout among OR nurses.

OR Bullying is Common

The statistics with regard to bullying in the OR are not encouraging. According to a study conducted by the Association of periOperative Registered Nurses (AORN), about six out of 10 (59 percent) perioperative nurses and surgical technicians said they had witnessed coworker bullying on a weekly basis.

Also, more than three out of 10 (34 percent) OR nurses in the survey said they had witnessed at least two bullying acts per week.

In a survey conducted by employment agency RNnetwork, nearly half (45 percent) of nurses said they have been verbally harassed or bullied by other nurses. Also, 41 percent said they’ve been verbally harassed or bullied by managers or administrators and 38 percent said they’ve been verbally harassed or bullied by physicians.

According to Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, the literature is consistent that health care organizations experience among the highest incidences of workplace bullying of any employment sector.

“These disruptive behaviors have the industry and all of its stakeholders on high alert,” Fink-Samnick says.

The Joint Commission has identified bullying as a Sentinel Event. It defines bullying as intimidating and disruptive behaviors that include “overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.”

The Workplace Bullying Institute defines bullying as “the repeated, health-harming mistreatment of one or more persons (or targets) by one or more perpetrators.” Bullying behavior is marked by abusive conduct that is threatening, humiliating or intimidating or leads to interference that prevents work from getting done.

Bullying behavior in the OR can be overt – like threats, physical violence or verbal harassment – or more subtle. Sometimes referred to as “incivility,” subtle harassment includes things like sabotage, exclusion, unequal treatment, unfair assignments and withholding information.

The Pecking Order of Bullying

Fink-Samnick says that many experts view bullying in the OR as a direct reflection of the power that stems from the traditional hierarchical stratification that is a hallmark of many health care organizations.

“The individuals at the top of the hierarchy – like c-suite and department leaders and surgeons – have the power to bully those below them solely by virtue of their position,” she says.

Some researchers believe that good old-fashioned competition tends to pit nurses against each other and lead to bullying. Their theory is that competition among mostly female nurses has shifted from attracting a man to achieving status and respect in their job as perioperative nurses.

Adds Fink-Samnick: “Most nurses can share at least one story reflecting the well-known stereotype that they ‘eat their young.’ ”

A study conducted by the Robert Wood Johnson Foundation determined that younger OR nurses are especially susceptible to being bullied by older and more experienced colleagues.

“Bullying in the OR grossly impacts patient quality and safety and traumatizes the workforce,” says Fink-Samnick. “The intimidating and disruptive behaviors associated with bullying fuel medical errors and lead to preventable adverse outcomes.”

For example, more than 75 percent of disruptive behaviors lead to medical errors, she says, while 30 percent of disruptive behaviors lead to patient deaths.

Factors Leading to Burnout

There are many factors that can lead to burnout among OR nurses, with bullying being just one of them. High stress, long shifts and physical exhaustion can also lead nurses to the point of what

Beth Genly MSN, the co-author of “Save Yourself From Burnout: A System to Get Your Life Back,” calls “soul-deep exhaustion.”

“Burnout among OR nurses can lead to withdrawal from work and life, as well as deep doubts about one’s ability to make a difference,” adds Genly. “It typically has three dimensions: emotional fatigue, cynicism and inefficacy.”

According to Erin Kyle, DNP, RN, CNOR, NEA-BC, Perioperative Practice Specialist with AORN, researchers have found relatively high rates of burnout syndrome among OR nurses.

“In the 2017 AORN Salary Survey, the vast majority of OR nurses who are planning to leave health care cited dissatisfaction with their work environment or culture,” says Kyle. “While this survey didn’t address burnout explicitly, some conclusions may be drawn from this response data about burnout.”

Kyle says there are both intrinsic and extrinsic factors that influence burnout among OR nurses. She identifies five intrinsic personality factors that place nurses at increased risk for burnout: neuroticism, agreeableness, conscientiousness, extraversion and openness to experience.

“Perioperative nurses who have personality traits that make them more susceptible to burnout are at increased risk to experience it when they are faced with extrinsic factors,” says Kyle. Extrinsic factors include things like the fast pace of the OR environment, minimal rest between on-call, moral dilemmas and ethical issues, and a harsh work culture.

There are several burnout risk factors that are unique to perioperative nursing, Kyle adds. “One is the fact that perioperative nurses are largely unknown to patients and their families because they are hidden behind the ‘double doors’ leading into the operating room.”

“Another is the increasing demands presented by rapid technology advances,” she adds.

“OR nurses are expected to have a vast knowledge base, be extraordinarily flexible and adaptive to change, and be critical thinkers,” says Kyle. “They’re also expected to balance what they see as the best care for patients with organizational demands to contain costs.”

“Over time, these pressures combined can drive excellent perioperative nurses into distress and eventually burnout,” Kyle concludes.

Five Areas of Focus

Genly has identified five specific areas where OR nurses should focus their efforts to avoid burnout:

1. Self-care: This is about whether you are taking care of the basic functions that keep your body going. “Self-care includes eating, sleeping, hydration and elimination – all of the functions that become troublesome if they are regularly interrupted or ignored,” says Genly.

2. Reflection and recognition: “This looks at your level of awareness of your own feelings and values, whether the people around you recognize your accomplishments, and whether you allow yourself to observe things for what they are,” says Genly.

3. Capacity: This has to do with how much stress you can take and your awareness of how close you are to this limit. “In other words, have you spread yourself too thin?” says Genly. “And if you have, are you aware of it?”

4. Community: This reflects the social elements in your life. “Do you feel connected with a community of people who share your values and have good intentions for your well-being?” says Genly. “If you do, are you having enough interaction with them?”

5. Coping skills: This looks at what types of coping methods you tend to use and whether they are helping or hurting you. “Included here are elements of how you actively deal with stress, as well as unconscious habits that you may not realize are types of coping methods,” says Genly.

A Shared Responsibility

Kyle says that OR nurses and health care organizations share responsibility for recognizing the risks of burnout and helping reduce this risk.

“Cultural problems like pervasive bullying sometimes exist in the perioperative setting that can affect not just one nurse, but the entire perioperative team,” says Kyle. “Health care organizations are responsible for cultivating a work environment that is supportive of perioperative nurses and other health care professionals.”