Addressing Bullying in the ED
AN recently conducted an interview about bullying with an ENA researcher.
allnurses.com staff recently had the opportunity to interview Lisa Wolf, PhD, RN, CEN, FAEN,
Director of ENA's Institute for Emergency Nursing Research. She has published research about bullying and how it affects nurses patient care.
How does bullying in the ED manifest itself?
Bullying can manifest as the dynamics of aggression, which includes overt hostility, denigrating comments, giving inappropriate assignments for the nurses' experience and expertise, and selective reporting. More difficult to identify and call out, however, are the dynamics of exclusion, which is marked by a withdrawal of help, support, and information. These types of behaviors often result in a nurse being "set up to fail", which has consequences for patient care.
How does this differ from bullying in other departments?
I don't know that it is very different in other departments, but the constant flow of patients, the short turnaround times, and the initial lack of knowledge about patient conditions makes the emergency department a particularly high risk area for this dynamic to manifest.
What kind of collateral damage results from bullying in the ED?
Workplace bullying is a significant factor in the dynamics of patient care, nursing work culture, and nursing retention. The impact on patient care cannot be overestimated, both in terms of errors, substandard care, and the negative effects of high turnover of experienced RNs who leave, compounded by the inexperience of newly hired RNs
What methods did you find to be the most effective in addressing / decreasing
Our respondents report that a "calling it out" strategy by both staff and management is the most effective way to reduce bullying and its consequences. An assessment of hospital work environments should include nurse perceptions of workplace bullying, and interventions should focus on effective managerial processes for handling workplace bullying
As a result of your research, what type of training do you recommend?
Given that management is the key role in mitigating bullying behaviors, education in the identification of bullying behaviors (especially those marked by the dynamic of exclusion) and in addressing them with staff is probably the most effective way to reduce workplace bullying.
Bullying is becoming more pervasive in our culture as a whole. However, as nurses on the forefront of life and death decisions, it is imperative that nurses have a toolkit to deal with bullying at work. The American Nurses Association published a position paper on this in 2015 with a goal; "to create and sustain a culture of respect, free of incivility, bullying and workplace violence."
ENA has also published guidelines to deal with and curb lateral violence which is defined as; "violence, or bullying, between colleagues (e.g. nurse/nurse, doctor/nurse, etc.)."
"According to a 2011 study by the Emergency Nurses Association (ENA), 54.5 percent out of 6,504 emergency nurses experienced physical violence and/or verbal abuse from a patient and/or visitor during the past week. The actual rate of incidences of violence is much higher as many incidents go unreported, due in part to the perception that assaults are "part of the job"."
ENA offers a toolkit with six distinct steps to address workplace violence. The first step is acknowledging that it exists and that nurses have the capability to decrease the incidence. There are many shareholders in this initiative including the front line staff but managers and administrators also have a key role in this. JCAHO, OSHA and other governmental agencies require documentation of a safe workplace and offer recommendations as well.
Violence should never be tolerated. Do you feel safe from lateral violence in your emergency department? What has your ED done to combat lateral violence?
Nov 3I understand that that culture of negativity and hurtful behavior amongst peers/coworkers is a very serious matter but I think ultimately it will be a disservice to nurses to conflate that with "violence in emergency departments." I have more than one "long-view" reason for feeling this way.Nov 4The way "lateral violence" manifested in my old ED was by favoritism in assignments, giving the clique the better assignments with more help from the ED techs. The bad assignments were the 4 patient POD assignments, especially one section that always had the patient with altered mentation that was trying to get out of bed or hit you without anyone to watch them except for us. In that particular POD we could get sick ICU patients who should be in one of the RESUS rooms but those were full. The management tried to address this by assigning a resource RN, a primary RN and a tech to sections of the ED which resulted in some relief, but not fully solving the issue of favoritism and unwillingness to value the less senior members of the team. I don't know if I would call this "violence" but made the department druggery for me after a while and I was glad to leave, though I do miss some poeple I worked with. We also had a doctor that was too high strung and at times stressful to work with.Nov 5Reducing regressive unprofessional attitudes by poorly trained and intellectually unqualified nurses to the term "bullying" is absurd. It just confirms to those that would criticize nursing as a profession that they are justified in their claims that nursing is more of a trade than a profession.
Is "bullying" a problem among medical staff? PA's, NP's, other advanced practice specialties? The answer is no and it is because of the way those groups are trained to think and act and solve problems. The traditional nursing education emphasis on the pseudo-science "nursing theory model" fosters a very weak intellectual framework for entering into practice with other medical professionals who have been trained in rigorous, challenging models in academic science and medicine.
Call the problem whatever suits, but until a fundamental change is made in nursing training, you'll have a certain subset of people acting like immature, unprofessional morons.Nov 6We will certainly never get anywhere when we have nurses that discount the whole concept like the above comments.
I almost didn't make it through my new grad orientation because my preceptor was such a bully. She's one of those "I know it all, my way is the only way, new grads shouldn't be here, there's only one way to teach," nurses. Every question was a manipulation, every statement an attack. Said things in front of patients that were wholy inappropriate. Nitpicked every tiny little thing. My orientation was 6 weeks over the maximum expected (16 weeks is expected, I went to 22) because she refused to help me get there and pushed me back. I was finally pulled off and given a new preceptor. 3 weeks and I was on my own! My new preceptor even told my manager he had no idea what the previous was on about, that I was doing fantastic. All the time I spent with her and I can't attribute much to her except my still fighting to get my confidence back. Now she refuses to take report when she's my relief because "she knows it all." Patients say she bullies them all the time too. #hownottopreceptLast edit by 3rdGenRN on Nov 6 : Reason: TyposNov 6Quote from 3rdGenRNWe will certainly never get anywhere when we have nurses that discount the whole concept like the above comments.
Well, you'll certainly won't get anywhere if the problems is totally mis-identified, anyway.Nov 10No offense, but why is this article going on about lateral violence and then using statistics showing an appallingly high level of non-lateral violence perpetrated by visitors and patients? It always seems to me that most discussions on workplace violence among nurses miss the elephant in the room. This article points right at it and then drops the subject entirely.Nov 12"According to a 2011 study by the Emergency Nurses Association (ENA), 54.5 percent out of 6,504 emergency nurses experienced physical violence and/or verbal abuse from a patient and/or visitor during the past week. The actual rate of incidences of violence is much higher as many incidents go unreported, due in part to the perception that assaults are "part of the job"."
I suspect that theses numbers are so high because the terms are not defined. The terms "violence" and "abuse" have pretty wide interpretation.
I doubt that 3/4 of ER nurses are weekly victims of what I would call violence or abuse.Nov 14"According to a 2011 study by the Emergency Nurses Association (ENA), 54.5 percent out of 6,504 emergency nurses experienced physical violence and/or verbal abuse from a patient and/or visitor during the past week. The actual rate of incidences of violence is much higher as many incidents go unreported, due in part to the perception that assaults are "part of the job"."
"Physical violence" and "verbal abuse" need to be defined further for the first statement to be meaningful, and "violence" and "assaults" need to be further defined in the second statement to render it meaningful.
I think it is important to keep in mind that many people who receive care in the ED are experiencing medical/psychological crises and cannot reasonably be held to the same standard of behavior as a medically/psychologically well person.
People who are ill may expend a huge amount of energy being ill and often don't have much/any energy left over for nice behavior. Also, being a patient in the ED is a stressful experience even if one is not seriously ill.
Emergency nursing by it's nature is not without risks to nurses and other staff members. In the local ED there is a security presence that seems to aim to balance being present when needed with not interfering with the care of patients/family members otherwise.Last edit by Susie2310 on Nov 14Nov 14Quote from JKL33I strongly agree with this, and I would add that I think it will be a disservice to patients too.I understand that that culture of negativity and hurtful behavior amongst peers/coworkers is a very serious matter but I think ultimately it will be a disservice to nurses to conflate that with "violence in emergency departments." I have more than one "long-view" reason for feeling this way.Last edit by Susie2310 on Nov 14
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