Only the light from the bathroom illuminated Jill's room as I walked in as quietly as possible. It was only 7:15 a.m. and I had received report on 4 patients. Two of them were new, but Jill and one other were patients from the previous day. I walked over to check Jill's IV infusions. I had told the night shift nurse in report last night to be sure to DC the antibiotics. I turned on a wall light for a better view and immediately saw a secondary bag hanging down, infusing antibiotics. I had 3 other busy patients and my plans for an organized morning just went all to heck. I closed the clamp on the secondary and made some notes in my notebook about the medication error, since I would not only have to write up an incident report and call the physician, but also tell the patient.
I found the night shift nurse who made the error. She was in her early twenties, with a cute brown ponytail, perky personality and had only been off orientation for 3 months. I proceeded to do what I swore I never would...that whole "eat your young" thing. I looked down at her, she was shorter by 4 inches, and in an exasperated tone said, "Katie, I told you to discontinue the antibiotics last night - didn't you see the order?" I could see her shock at being spoken to that way combined with the shock of realizing she had made an error. Her eyes widened and she looked away saying, "I can't believe I forgot, I am so sorry." I started feeling bad about my how I was speaking to her immediately, but also felt powerless to stop it at the time. I know I said something else like, "I will have to fill out the incident report..." with a heavy sigh, so she would understand just how much extra work she was causing me.
I stalked off, visibly irritated, and she went home. I recall feeling triggered by worry that I was somehow responsible for the error - that I hadn't been clear at shift change, and that fed my reactivity. I felt like a failure - could I have communicated better the night before? Someone who witnessed the exchange let the supervisor know and she called me in that afternoon and we talked about it. I told her I knew I had been rude, and that I felt terrible. We talked about my stress level and strategies for being direct without being unkind. I found Katie's home phone number and called her late in the day saying, "Katie, I must have made you feel terrible - you are a new nurse and all I want to do is support you. I lost my temper and I was unkind. I am so sorry, and I hope you can forgive me." She said she understood, but an apology doesn't take away the hurt or the damage. I wish I could remember her last name - this incident happened 7 years ago, but it is still so clear in my mind, and I wonder if it is as clear in hers? I wonder if she is still a nurse?
I was never rude to her again, but during my career as a nurse, I have had repeated incidents like these where I behaved with incivility.
Problems
More than half of nurses report being verbally abused at some point in the past year Bullying, workplace incivility, lateral (horizontal) violence - these are hot topics right now, and they should be. There is an urgent reason to change the culture of nursing from one in which "nurses eat their young". The Joint Commission reviewed 936 sentinel events in 2015. Over half of them resulted in patient death. The most frequently reported events were things like leaving a piece of surgical equipment in a patient, doing the wrong procedure on the wrong site of the wrong patient, and patient falls. What does this have to do with bullying? The top three most frequently identified root causes for these events were human factors like competency assessment and staff supervision, leadership issues like complaint resolution and communication among staff, administration and patients and families. From these statistics, we can infer that reducing workplace incivility and lateral violence has the capacity to reduce harm to patients.
We have known for a long time that improved communication will result in safer patient care. There is a whole chapter in Robert Wachter's book, Understanding Patient Safety (2012) on teamwork and communication. Every morning I wake up and check Twitter, Linked in and Facebook for patient safety posts, articles and information and many of them are about bullying. I was recently at the North Carolina Nurses Association Conference and there were two workshops on workplace incivility. Browsing through continuing education offerings yields multiple courses available for CE on the topic. There is even nurse bullying specialist, Dr. Renee Thompson.
Definitions
The ANA defines incivility as rude and discourteous actions, gossiping, spreading rumors, or refusing to assist a coworker. This may include name-calling, using a condescending tone, or expressing public criticism. The dictionary defines a bully as a person who uses strength or power to harm or intimidate those who are weaker. The ANA states bullying is "repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient, including actions that harm, undermine and degrade. Examples include hostile remarks, verbal attacks, threats, taunts, intimidation, and withholding of support."
Dr. Renee Thompson, DNP, RN, CMSRN, a bullying specialist (Renee Thompson Speaks), defines bullying as a repeated pattern of destructive behavior with the conscious or unconscious attempt to do harm. It can be overt, as in the case of a nurse criticizing you at the nurses' station, or it can be covert, as in a nurse who offers to help you and then talks about how lazy you are behind your back. Taken a step further bullying can become "mobbing" when more than one person commits egregious acts to control, harm and eliminate a targeted individual.
It's important to remember that bullying is a behavior, not an identity. That's a quote from Teaching Tolerance (There Are No Bullies | Teaching Tolerance). This article talks about motives of power and control. Bullying behaviors are strategic behaviors that are there for a reason - to fill a need. The author states that there are people who deliberately and intentionally try to hurt others, wanting to dominate and feel powerful. The question is, why do they have this need for control and power?
I haven't been able to find any scholarly research on links between bullying behavior and childhood trauma - if you have any information about this, please let me know. Based on my own past and on what I know about trauma-informed care and the Adverse Childhood Events Study (ACEs study; Adverse Childhood Experiences Study - Wikipedia), I do know that trauma in childhood causes lasting changes to the nervous system. It creates reactivity that pre-dispose survivors to a fight or flight response to real and imagined triggers. There are estimates that more than 50% of adults have experienced a traumatic childhood event. There may be a link there. What I have trouble believing is that some people are just "mean". I searched the internet, google scholar and pubmed for information about characteristics of adult bullies, bullying behavior in adults, why do adults bully, and help for bullies and found nothing.
One indirect link I found - according to bullying experts Dan Olweus, Sue Limber and Sharon F. Mahalic, 60 percent of boys who bullied others in middle school had at least one criminal conviction by the age of 24; 40 percent had three or more convictions. A recent study published in the Journal of the American Medical Association reported that youth who bully are at increased risk for depression, conduct disorders, substance abuse and suicide. Does the bullying lead to these consequences, or are people with mental health challenges more likely to demonstrate bullying behavior?
Expectations
The American Nurses Association issued a 23-page position statement in July of 2015 on Incivility, Bullying and Workplace Violence. "As nurses, we are required to create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students and others with dignity and respect"
The expectation is that we behave with professionalism. Where do the rules of professionalism for nursing come from? What are the rules? My husband has been a successful physical therapist for over 10 years, and he suggested that the expectations of professionalism are very specific to the profession. Behavior that would be tolerated, or even expected from a top cardiac surgeon would be grounds for termination for an RN. Professional standards are related to gender, level of experience, how you look, power, position and what you do for a living. Is it any wonder we have difficulty at times knowing what is expected of us? It's hard to watch others getting away with bad behavior day after day with no consequences. Even worse is to experience consequences for that same bad behavior, while watching others continue to "get away with it".
Are our expectations too high? Are they wrong? Should we even have them? Who makes the rules? In an ideal world, we would treat each other with respect and kindness all the time. However, we don't live in an ideal world. It seems to get more "un"civil with every passing moment. I'm not suggesting the ANA position statement on workplace behaviors is wrong, I am suggesting that it may be hard to follow. It may be hard to measure up to. And what about the person who is the bully without even know they are a bully? Article after article discusses how to know if you are being bullied and what to do about it, but what about the bully herself?
Dr. Renee Thompson has a tool "what if the bully is you" which I took a look at. I answered "sometimes" to 6 of the 15 criteria. Yes, I sometimes roll my eyes or make mean faces behind other people's backs, I sometimes talk about others in a negative way when they aren't around, sometimes other people seem unreasonably upset by the things I say or do, and yes, I have been told I intimidate other people. Worst of all I have actually made people cry at work. This has got to stop - it's not ok. I don't want to make people cry. I don't want to be intimidating. I do need to vent occasionally, but want it to be in a way that doesn't harm anyone else.
At the bottom of the survey are these words: "If you answered sometimes or frequently to one or more questions, you are displaying behaviors that could be considered bullying if repeated over time. The first step is self-awareness. The second step is adapting your behavior."
Solutions
It's tough to figure all this out because we don't talk about it, especially if we are the bully. And we don't have a way to find out because the information is hidden - there is no report of people who have been written up, people who have had coffee talks, people who have been "in trouble" people who have been fired. How do we collect statistics on something for which there is no data?
Dr. Thompson is the bullying specialist, and I have read over many of her free materials and resources. She gives straightforward advice on how to handle bullies: document the behaviors, name the behaviors by directly speaking to the bully, and don't tolerate bullying. I highly recommend visiting her website to get bullying resources.
We need to open a discussion about prevention. There are tools for identifying if you are at risk for being the bully, and tools for identifying those at risk for being bullied. Dr. Thompson says self-awareness is the first step, followed by adaptation. I am looking for adaptation tools.
I have decided (obviously) to keep trying. I won't give up. I'm so interested in body therapies - not the standard talk therapy I have experienced for the past 20 years or so, but techniques that are new to me. I will keep writing and hope to hear from others out there who are the mean girls, who are intimidating, who have made people cry. If we hide in shame, we can't improve. If we hate the hater, no one wins.
I like to speak my mind, but I wonder if there's a use or space for nurses who speak their mind? My husband reminds me of the many people who succeed in the professional world by keeping their mouths shut. I remember over and over again in nursing school my fellow students would say, "Kristi, stay under the radar!" Flying low has never been my style when confronted with perceived injustice or wrongs.
I have been asked to resign, told I am rude, and been written up for insubordination. Should I just quit? Should I just go live in a cave? What is the answer for someone like me with a huge heart and a reactive personality? I think I am worth keeping around. I live in here - in my head and I know what a good person I am. I'm not justifying my behavior or suggesting I should not experience consequences. What I am doing is letting you know what goes on inside the head of someone like me. This is what's happening in the head of this possible bully. My close friends would tell you that I'm worth it. The results I get with my research and the work I do at church suggest to me I'm worth it. I don't want to be seen as a liability, as a difficult person. I challenge people and I don't always do it in a thoughtful or kind manner.
I know what is expected of me. I know what I am supposed to do. I continue to struggle with doing it. If I am triggered, I may react. I am so sick and tired of it. I am tired of that reactivity. I have so much to offer and I so want to be a part of the solution; but if I can't get a handle on my behaviors, I will continue to lose credibility.
I'm confused and conflicted on several points, which I will present for your consideration. First of all, I have a hard time believing anyone would behave this way intentionally. As a person who has in the past behaved with incivility, I can state from my perspective that it was never on purpose. My intention at the start of each day is to create an ethical environment; a culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect (ANA position statement).
I do believe that my history of childhood trauma makes it more likely that I will react to stressful situations with my primitive, sympathetic nervous system - responding in a fight or flight manner that can result in harmful words and actions on my part. I am not making excuses for my behavior, only seeking to understand it, hoping that in understanding I can finally at long last conquer it. As I write these words, I am flooded with shame at the memory of some of the things I have said and done in reaction to a perceived threat, despite lifelong therapy and work towards being a professional who behaves with professionalism.
This brings up several more questions that I have asked myself after behaving badly yet again. Are there some people who should just not be nurses, despite feeling called? Are there ways to know early on that you are not suited temperamentally to the job of nursing? What support or resources are there for people like myself who love nursing, are dedicated to the profession, yet who also behave with incivility? Am I the only one? I don't think so. Are there others out there who "get in trouble" for speaking out? Who are counseled on inappropriate behavior? Who has been written up for rudeness? I think there are. And that brings me to the final question. What should nursing do with us? Do we say to all these people, "don't be a nurse if you can't behave"? I get it, I understand that sentiment because I have thought it myself. I wonder if there is perhaps another way? Is there room in nursing for healing? How we approach the bully may be the key to saving ourselves.
I am asking you to consider several things as you deal with workplace violence and incivility. Consider how you deal with the perpetrator. It's one thing to recommend or refer to the Employee Assistance Network, it's another to proactively provide tools and information to support healing. I am learning a great deal about bodywork. The person who responds reactively (rudely, with incivility) is often not in control. We say "control yourself" without realizing that isn't possible. The control has to come before the stressor. Those of us with a reactive brain have to retrain ourselves to respond differently so we don't react in the moment, and there are many tools out there to do this - tools which in my 25 years of therapy I am just now finding out about. I have even been reading some research that suggests that talk therapy may interfere with healing from childhood trauma. The discovery that I may have been doing it "wrong" for 25 years
Experts in childhood bullying recommend that instead of talking about bullying and labeling people as "bullies" and "victims", we talk about healthy relationships, behaviors, rights, and choices. We tend to assume that people get this information as children, but so many don't. Empathy is key, as well as adopting comprehensive programming designed to promote social and emotional competencies (There Are No Bullies | Teaching Tolerance).
What if the next time someone behaves with incivility to me, I approach them with curiosity and an open heart? Instead of thinking "there are just some people who are mean", perhaps I can reframe that to "everyone is hurting from something, and we all manifest it differently". Instead of assuming that we all know "the rules" I could assume we don't and provide support and resources for nurses who are struggling with their behavior. I am not making excuses or asking for special treatment. I am not saying it's ok to be mean, to behave with incivility, or to be a bully. What I am suggesting is that through education and open discussion we can create healing. That's what nursing is all about - creating a healing environment for everyone, including those who challenge us.
