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Nurses Unite: Ending Incivility and Bullying

Few would disagree that society has seen growing levels of incivility and bullying in recent years. Unfortunately, this incivility has spread to many workplaces, including hospital operating rooms.

In fact, the health care industry experiences some of the highest levels of bullying across all industry sectors. Up to half of all nurses say they have been bullied in some manner in the workplace, according to the American Nurses Association (ANA). 

Fifty percent of nurses say they have been bullied by a peer while 42% have been bullied by someone at a higher level of authority, according to ANA. Meanwhile, nearly one in four nurses (25 %) say they have been physically assaulted at work and one in 10 (10 %)  say they are concerned about their physical safety at work. 

A Dangerous Problem

“Incivility in health care has been investigated by researchers and we know it is a problem among nurses in a variety of settings, including the perioperative environment,” says Erin Kyle, DNP, RN, CNOR, NEA-BC, editor in chief, Guidelines for Perioperative Practice for the Association of peri-Operative Registered Nurses (AORN).

“Incivility and bullying in the operating room is a common but dangerous problem,” adds Ruth P. Shumaker, BSN, RN, CNOR, executive director, perioperative services, Regional One Health. She cites an AORN Journal article which notes that 88% of nurses have witnessed physician incivility and 48% of physicians have witnessed nurse incivility.

While serving on the 2021 Task Force for Civility in the Workforce, Shumaker and her colleagues conducted a comprehensive review of the literature. 

“Unfortunately, this revealed that incivility is widespread in nursing,” she says. “While mistreatment in nursing was mentioned in the literature as early as 1980, it really started to surface in the early 2000s and has steadily increased since then.”

Deborah L. Spratt, MPA, BSN, RN, CNOR, CHL, independent perioperative consultant, says that bullying behavior can be physical, emotional, sexual, social, verbal or racial. 

“When I first started in the OR almost 50 years ago, I would have attributed the behavior to the perceived difference in status of the various team members,” Spratt says.

“Back in those days, surgeons were held in much higher esteem than other perioperative team members and bad behavior was allowed because they were the money makers,” says Spratt. “To some extent this attitude continues, but there is also now a nurse-to-nurse component, as well as nurses to other team members.”

Based on her literature review, Maria Sullivan, MSN, MMHC, RN, CNOR, says that more than seven out of 10 nurses have experienced incivility. 

“The problem of incivility began mainly with perioperative team members, but it has now extended to patients also being uncivil,” Sullivan says.

Defining Incivility and Bullying

The ANA defines incivility as “one or more rude, discourteous or disrespectful actions that may or may not have a negative intent behind them.” And it defines bullying as “repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient.”

Incivility is often a precursor to bullying. It can take many different forms,
some of them subtle:
Gossiping and rumor spreading

  • Eye-rolling and name-calling
  • Using a condescending tone
  • Public criticism
  • Refusing to help a coworker
  • Withholding information and sabotage
  • Social exclusion 
  • Hostile, snide and rude remarks
  • Passive-aggressive behavior
  • Scapegoating and backstabbing
  • Failure to respect privacy
  • Bullying takes incivility to the next level with actions such as:
  • Hostile remarks
  • Verbal attacks and threats
  • Taunts and intimidation
  • Withholding of support
  • Harmful actions intended to intimidate
  • Workplace “mobbing”

Kyle says that she has personally witnessed the consequences of incivility and bullying in the OR. 

“These memories are some of the most vivid from early in my career,” she says. “On the other hand, I have also witnessed civil behaviors that can turn the situation around. The individuals who took the initiative to stop the patterns of incivility made all the difference in those moments.”

“During the span of my nursing career, I have witnessed and/or experienced verbal, and on a more intense level what verged on the threat of physical, harm,” says Shumaker. “Overt aggression, bullying and abusive behaviors are often purposely intended.”

Other personal observations of incivility in the perioperative environment Shumaker has witnessed include shouting, intimating body language, talking down to others, making demeaning remarks and not listening. “I have also observed abuse and misuse of power by leaders and supervisors,” she says.

Spratt tells of a Primary Service Nurse who was known for keeping an instrument in her locker that was always needed for a particular case so that when no one was able to find it, she did and looked like a hero. “I have also seen a scrub nurse send the circulator out of the room for an item later recognized to be on the back table,” she says.

“And once, many years ago, I saw a surgeon throw a knife in frustration,” says Spratt. “That never happened again.”

What Causes Incivility?

There are many different possible causes of incivility and bullying in the OR. 

“It could just be the way someone’s day started,” says Sullivan. “Maybe they snapped at the person who came in to help them get their case ready, and that person feels hurt and decides not to bring in the tray that’s in the sterilizer. This can have a ripple effect and lead to compromises in patient care.”

Kyle cites issues that are common in the perioperative environment as potentially triggering incivility such as high stress, a hierarchical structure and a culture that tolerates incivility. 

“I believe you can’t change people’s basic personalities,” says Spratt. “Once a bully, always a bully, and you find bullies in all professions. There’s also the stress of time pressure in the OR where time means money, so its push, push to get cases done and start the next case.”

“Incivility in the OR may be caused by a shortage of experienced personnel, extreme work demands, high patient acuity, a lack of teamwork and a lack of respect for coworkers,” says Shumaker. “Also, the pandemic exposed nurses to conditions they weren’t familiar with, causing more stress, burnout and problems with coworkers.”

Consequences of Incivility

It’s not surprising that incivility and bullying can have serious consequences on the well-being of health care workers and patients. “Incivility is probably the biggest threat to patient safety in the operating room today,” says Kyle. “This is because perioperative team members who do not feel secure and supported in the practice environment are not able to practice at their best.”

Sullivan also worries about the effects of incivility and bullying on patient safety. “If you are working with a surgeon or anesthesia team member who has been less than kind to you in the past, you might be reluctant to stop the line and speak up for patient safety,” she says.

“There are also the psychological effects on nurses who have been bullied by other team members,” Sullivan adds.

According to Kyle, perioperative team members who are subjected to incivility and bullying in the workplace report a wide range of physical, psychological and behavioral disturbances including:

  • Insomnia, dizziness and fatigue
  • Irritable bowel syndrome
  • Abdominal and back pain
  • Hypertension and headaches
  • Loss of appetite and self-confidence
  • Rage, aggression and irritability
  • Anxiety and panic attacks
  • Depression and PTSD
  • Inability to relax
  • Suicidal ideation

“In a 2018 study, researchers found that the suicide rate among nurses, especially female nurses, is significantly higher than the general population,” says Kyle. “I think it would be foolish to ignore the connection between the psychological consequences of incivility and the high rate of suicide among nurses.”

Spratt says that incivility and bullying can increase the risk of “never events” like wrong patient/wrong site surgery, retained foreign bodies, and specimen and medication errors. 

“Nurses who are bullied are also more likely to leave the profession,” says Spratt. “Right now, older nurses are retiring and younger nurses are leaving the bedside in droves. New nurses with a healthy self-esteem may just decide to go into another line of work.”

Supporting Civility

The topic of incivility in the OR is so important that AORN has partnered with the American Association of Nurse Anesthesiology (AANA) and the American Society of PeriAnesthesia Nurses (ASPAN) to create a position statement on workplace incivility.

“Every perioperative team should be aware of the position statement and integrate it into their practice,” says Kyle.

The position statement clarifies that it’s the responsibility of employers and all health care professionals to create an environment that’s free of distracting, disruptive or violent behavior. It also clarifies the difference between incivility and bullying.

Incivility is addressed by transforming culture, according to the position statement, while bullying is commonly addressed in workplace policy and the code of conduct. “The mission, values and code of conduct of a health care setting should address the importance of a healthy work culture,” says the statement.

“Everyone has a role in workplace civility,” says Kyle, who lists a number of steps that can be taken to improve civility in the perioperative environment. Those steps are:

Conduct a full workplace assessment of conflict and disruptive behaviors to inform a workplace violence prevention program as recommended by OSHA.

Make cultivating and maintaining a culture of safety a priority at all levels of the organization by adopting a zero-tolerance policy and providing employee support to address uncivil and bullying experiences.

Use an interdisciplinary approach when leading teams through education and implementation of workplace civility programs.

“Multidisciplinary team training is a great place to start,” says Spratt. “Team training in a casual setting, using round tables and with assigned projects, is a great way to break the ice between team members who may not even know each other’s names.”

Some universities are now putting medical and nursing students in the same classes so they can learn to work together right from the beginning, adds Spratt.

“Also be willing to stand up for yourself and your colleagues,” says Spratt. “Don’t participate in the behavior and don’t hesitate to report up the chain of command. If you can’t handle a situation, call for help. That’s what leadership is there for: to provide an atmosphere that lets you do your job in a safe manner.”

Sullivan concurs.

 “It starts with leadership laying the foundation for the type of workplace they want to foster and then holding all team members accountable for behavior that does not meet that expectation,” Sullivan says.

“Leaders are integral in establishing a respectful and positive workplace culture,” adds Shumaker. “Health care institutions must provide a system where employees can report incivility and bullying without fear of retaliation.”

Sullivan sums it up best.

“Be kind and give grace,” she says. “And don’t accept bullying behaviors. Alert management if they occur so they can be resolved quickly.”  

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