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Vertical Violence & Workplace Bullying

Vertical Violence & Workplace Bullying
By Don Sadler

Workplace bullying is a common problem in many organizations today and, unfortunately, the health care setting is no exception.

According to the American Nurses Association’s (ANA) 2019-2020 Healthy Nurse, Healthy Nation (HNHN) Survey, nearly a quarter (23%) of nurses said they have experienced bullying from those in authority (or vertical violence) while nearly a third (31%) have experienced bullying from a peer (or horizontal violence).

Health Care Isn’t Immune

“Unfortunately, health care is not immune to workplace drama,” says Joseph Grenny, a cofounder of VitalSmarts and coauthor of the bestselling book Crucial Conversations. “The problem of bullying among nurses is chronic and pervasive.”

“If anything, the stress and complexities of long and difficult hours and power differentials among colleagues ensure that health care professionals will face interpersonal strain and frustration at every turn,” Grenny adds.

Research performed by VitalSmarts indicates that more than three-fourths of caregivers regularly work with doctors or nurses who are condescending, insulting or rude. Meanwhile, one-third say they’ve experienced behavior that’s even worse than this, such as name-calling, yelling and swearing.

“Perhaps the biggest challenge isn’t so much that bullying exists, but that it’s perceived by many as unsolvable,” says Grenny. “According to our latest study, 79% of nurses said solving the problem of vertical violence from a difficult peer was barely or not at all solvable.”

According to Ruth Francis, MPH, MCHES, senior policy advisor at the ANA, bullying can be covert or overt. “Covert acts include withholding information, exclusion, unfair assignments, sighs and annoyed glances,” she says. “Overt acts incude openly criticizing and purposely embarrassing peers in front of others, blaming others and ethnic jokes or slurs.”

Sharon A. McNamara, BSN, MS, RN, CNOR, agrees that vertical violence has been an issue in the health care environment in the past and remains one today.

“This problem is one of the major issues in health care and perioperative practice because it breaks down effective communication and teamwork and places both the practitioner and the patient in unsafe conditions,” she says.

McNamara prefers to discuss workplace bullying within the context of the term ‘incivility,’ which she defines as rude, disruptive, intimidating and undesirable behaviors that are directed toward another person.

“Behaviors I have seen include intimidation through actions intended to frighten or coerce, threats to cause physical or mental harm, physical attacks, property damage (like shoes filled with water and family pictures on lockers defaced) and even sexual harassment,” says McNamara.

“I also have observed that because the perioperative team functions with a small team in an isolated room behind the closed doors of the operating room, the practice is more frequent,” McNamara adds. “Working in these teams creates unique relationships that may foster tolerance of the inappropriate behavior, which is often rationalized as humor or ‘just his or her personality.’”

Vertical Violence & Workplace Bullying

Factors Leading to Bullying

There are many factors unique to the perioperative environment that can lead to workplace bullying, whether it’s vertical or horizontal violence.

“In the operating room, some of the unique stressors are the time pressures of the surgical environment and the patient being under anesthesia,” says Renae Battié, MN, RN, CNOR, vice president of nursing with the Association of periOperative Registered Nurses (AORN).

“These pressures can lead to impatience among less experienced team members who aren’t as efficient with tasks and responses,” Battié adds. “Of course, stress, fatigue and fear also contribute to negative behaviors.”

Francis notes that in the HNHN Survey, 77% of nurses said that workplace stress is a work hazard and concern for them. “Perioperative work has long shifts, is crisis-oriented and is high pressure,” she says. “Not that this is an excuse, but stress can cause a breakdown in the teamwork and incite anger and hostility, which creates a breeding ground for bullying.”

Not surprisingly, the coronavirus pandemic appears to have made the problem of bullying in the OR worse.

“While the current pandemic has created stress for everyone, this is even more true for nurses and other health care professionals who are concerned about maintaining their own health, keeping their families safe and also taking care of potentially high-risk patients,” says Francis.

“When stress increases like it has during the pandemic, those with greater perceived power often express more aggression and those who perceive themselves as less powerful often believe their only option is to submit,” adds Grenny.

However, McNamara points out that many health care workers are at their best while in crisis mode. “Everyone fires on all cylinders, teamwork kicks in and we are more aware of the needs of the patient and each other,” she says.

“Granted this cannot be maintained indefinitely, which may add to the breakdown in individuals’ behavior,” McNamara adds. “We must be alert for the aftermath and its effects – which may be far more reaching as nurses struggle to recoup physically, emotionally and psychologically while expected to carry on.”

Zero Tolerance for Bullying

Addressing the problem of workplace bullying starts with creating a culture of safety and a zero-tolerance policy throughout the organization, says Francis.

“The ANA’s Incivility, Bullying, and Workplace Violence Prevention Position Statement provides guidelines for nurses and their employers,” Francis says. “Employers should increase the awareness of staff to the statement by providing training to recognize behaviors and know what actions to take.”

Specifically, nurses should know what the facility policies are and should not be afraid to speak up when an incident occurs. “Reporting inappropriate behavior should never have repercussions,” says Francis.

The ANA’s #EndNurseAbuse website ( contains educational materials, an issues brief, legislative information and flyers for nurses to learn more about protecting themselves and others from abuse, as well as prevention strategies to keep the workplace safe.

“Our research confirms that if you can talk about bullying, you can solve it,” says Grenny. “Within most health care teams, however, few people feel comfortable speaking up and addressing it.

“But there is hope,” Grenny adds. “Specifically, when managers are trained in the skills to engage in crucial conversations and hold people accountable, organizations experienced less bullying. And when bullying did occur, it was both discussable and solvable.”

In research conducted by VitalSmarts, hospitals staffed with leaders who have created a culture of open dialog where honest conversation is the norm when problems arise scored:

  • 16% higher on patient safety
  • 18% higher on quality of care
  • 19% higher on patient experience
  • 37% higher on staff engagement

“The key to overcoming workplace bullying is to create strong norms that prohibit it,” says Grenny. “This type of behavior stops when norms change.”

The Importance of Mentoring

In this environment, Battié stresses the importance of older and more experienced perioperative nurses mentoring younger and newer nurses. “The effective communication and conflict management skills that more experienced nurses have are a very important element of the mentoring that is needed for younger nurses,” she says.

McNamara agrees.

“Now is the time for action when these master perioperative nurses must share with younger nurses their knowledge, skills and personal bag of tricks that have allowed them to provide safe, quality care,” she says. “I challenge experienced nurses to adopt a novice nurse with the intention of making her or him a firestorm for patients and future practitioners.”



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