Bullying, Mentoring, and Patient Care DOROTHEA FREDERICK, MSN, CNOR
ABSTRACT The literature suggests that acts of bullying are a root cause of new nurses leaving their units or the profession entirely and have the potential to worsen the nursing shortage. As an effective way to address bullying in the perioperative setting, mentoring benefits the nursing profession. Mentoring can have a direct influence on nurses’ longevity in a health care organization, thereby strengthening the nursing workforce. Magnet-designated hospitals support the importance of mentor-mentee relationships for positive employee retention and positive recruitment outcomes. One of the most important tasks that a mentor should undertake is that of a role model. Establishing a culture of mentoring requires authentic leadership, genuine caring and respect for employees, and open communication. The entire nursing profession benefits from a culture of mentoring, as do the patients and families who receive care. AORN J 99 (May 2014) 587-593. Ó AORN, Inc, 2014. http:// dx.doi.org/10.1016/j.aorn.2013.10.023 Key words: mentoring, bullying, authentic leadership, longevity, staffing, role modeling, debriefing, professional conduct, Magnet.
B
ullying should not occur in a profession dedicated to caring and compassion,1 and yet “nurses eat their young” is an expression that is familiar to all nurses.2 Estimates suggest that more than 80% of nurses experience bullying at some point in their working lives.3 As a travel nurse who works in the OR, I am aware of the factors that contribute to a changing workforce and the requirement for agency services and travel nurses. I have witnessed nurse-to-nurse bullying, most often between mentors and mentees. For example, I have observed nurses who refuse to mentor, nurses who withhold information, and nurses who simply ignore their mentees. The literature suggests that there is a link between these
behaviors and high rates of employee turnover, incivility, and decreased quality of care.4 Mentoring is an important strategy for addressing bullying in the workplace setting. Mentoring can be defined as an intense relationship between a novice and expert practitioner that promotes role socialization, creates a supportive environment, fills the gap between didactic and real-world experience, and results in ultimate role success of the novice.5(p161) Mentoring cultivates nurse leaders, improves team morale, and retains nurses. The entire nursing profession benefits from a culture of mentoring, as
http://dx.doi.org/10.1016/j.aorn.2013.10.023
Ó AORN, Inc, 2014
May 2014
Vol 99 No 5
AORN Journal j 587
May 2014
Vol 99 No 5
do the patients and families who receive care. According to the 2010 Institute of Medicine report on the future of nursing, mentoring is an effective way to strengthen the nursing workforce and improve the quality of care and patient outcomes.2 This article examines bullying as a key contributor to the instability of the nursing workforce and mentoring as a solution for change. Mentoring allows perioperative teams to respond to bullying in a positive manner and to modify inappropriate behavior. A mentoring culture begins with authentic leadership, genuine caring and respect for employees, and open communication. BULLYING The Workplace Bullying Institute defines workplace bullying as repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators that takes one or more of the following forms: n
verbal abuse; n offensive conduct/behaviors (including nonverbal) [that] are threatening, humiliating, or intimidating; and n work interferencedsabotaged[that] prevents work from getting done.6 Other terms associated with bullying are workplace incivility, horizontal hostility, lateral violence, and hazing. The victim of bullying often is subjected to two or more negative incidents per week during a six-month period.4 The difference between bullying and other types of conflict is a power disparity that exists between the bully and the victim. Behaviors can be subtle and nonaggressive, making it difficult for a victim to prove that he or she is a target of aggression.4 Acts of aggression may include personal attack, attack on reputation or competency, and attack through work tasks.7 Why Nurses Bully Nurses who bully other nurses have been characterized as having high levels of self-interest, a need 588 j AORN Journal
FREDERICK for power, and personal or psychological problems.8 Regarding nurse-to-nurse bullying, the bully is usually an experienced nurse in a mentoring role to a new nurse, who is the victim. Mentors who bully novice nurses show patterns of abuse, such as allowing new nurses to struggle or setting them up to fail and then coming to the rescue of the situation. Consider the following example: A surgeon says a procedure will be short and routine and that electrocautery will not be needed. During the course of the procedure, the situation changes and the surgeon requires electrocautery. The new nurse looks questioningly at her mentor about how to apply the grounding pad to a draped patient, but the mentor offers no suggestions. The mentee does not know what is required, the surgeon gets frustrated with the new nurse, and only then does the experienced nurse intervene. In this scenario, if the mentor had not engaged in bullying behavior, she would have simply given instructive guidance to the new nurse. As a result, the new nurse would have proceeded correctly and been able to control the situation, and the procedure would have gone smoothly. To understand the cause of nurse-to-nurse bullying, Weaver’s analysis9 suggests that nurses who bully are responding to a sense of powerlessness they experience because of the dominant influence of physicians and administrators. For nurses, feelings of powerlessness can lead to feelings of oppression, which can manifest as aggression. According to Weaver,9 nurses who bully are those who feel the power imbalance associated with restricted autonomy and autocratic leadership. In this framework of analysis, nurses respond to feelings of powerlessness and a perceived lack of control through bullying and aggressive behaviors, which negatively affect their clinical practice and professional relationships. Normalization of the bullying behavior occurs when perioperative team members (ie, bystanders) tolerate it as being common to the practice setting.7 The inaction of bystanders, whether out of fear of becoming the next victim, or because the culture does not
BULLYING, MENTORING, AND PATIENT CARE
www.aornjournal.org
support confrontation of the abuse, empowers the bully. 10
of value, lack of professional stimulation, and inadequate support and mentoring.12 In some cases, turnover may be beneficial to facilities in terms Effects of Bullying of reducing costs because of decreased salaries, New nurses are often the victims of bullying. The providing better matches of employees to employknowledge that nurses attain in nursing school is ment, and infusing new knowledge and ideas. Inthe required preparation for clinical practice, but consistencies in nursing turnover definitions and it does not necessarily prepare them for the reality methodology limit the ability to compare turnover of nursing. The fact that new nurses are clinically rates between units and across jurisdictions over untested can be pertime; however, esticeived as an invitation mates suggest that for bullying behavior The inaction of bystanders, whether out of fear nurse turnover will by experienced nurses, of becoming the next victim, or because the reach 50% within the culture does not support confrontation of who feel justified in first three years of abuse, empowers the bully. their harsh treatment clinical practice.13,14 of new graduates Therefore, turnover because their commost likely has nega9 petency is not trusted. Bullying and disretive implications as a threat to the stability of the spectful behaviors from experienced nurses nursing profession.13 toward new graduates have been shown to In the United States, nursing workforce proinhibit new nurses’ learning and growth and jections indicate that the RN shortage may exceed 9 stunt their potential. 500,000 RNs by 2025, according to the American Johnson and Rea4 suggest that bullying behavior Association of Colleges of Nursing.14,15 In 2012, is more predictive of a victim’s intent to leave the the Bureau of Labor Statistics reported data that profession than satisfaction with salary. New nurses project the number of employed nurses will grow not only leave their units to avoid being bullied but from 2.74 million in 2010 to 3.45 million in 2020 potentially leave the profession entirely.9 MacKusick (ie, 712,000 new jobs, or an increase of 26%).16 At and Minick11 relate the following from a new RN a time when health care is expanding, however, practicing for two months on the night shift. estimates suggest that 30% to 50% of all new RNs are at risk of leaving their current jobs within their I was totally alone . . . one patient in what I first three years of practice.11,17 It is critically imthought was SVT [supraventricular tachycardia], portant to address factors that contribute to fewer one pulling out all of his lines because he was nurses being available to provide care or to meet disoriented, and one who really seemed to have staffing needs. Included in these factors are bula hard time breathing. The RNs in the break lying and lack of mentoring. room said they would be there in a minute. I called the supervisor, [who] told me to find my MENTORING AS A SOLUTION mentor. I was all alone, all the time.11(p337) Mentoring encompasses both an emotional and a transitional relationship in which the experienced This new nurse left clinical nursing after one year.9 professional teaches, guides, and serves as a model Bullying behaviors can have an adverse effect for the less experienced person; nurses who care on a victim’s job satisfaction but also on overall and offer wisdom to other nurses are mentoring.18 nursing retention.4 Among the reasons that nurses cite for leaving positions or the profession are lack New OR nurses, as they transition from graduate to of appreciation from superiors, a diminished sense experienced perioperative nurses, are expected to AORN Journal j 589
May 2014
Vol 99 No 5
FREDERICK
function at an advanced level. There is a challenge and the mentee or from the triad perspective as to provide safe and competent care to patients as an organizational phenomenon among the mentee, they continue to fill the gaps in their knowledge. the mentor, and the organization.25 The triad apMentors help them develop advanced clinical skills proach reflects the MagnetÒ philosophy and is along with critical thinking while maintaining consistent with a positive mentoring work envi5 a nursing focus. Organizational knowledge is ronment. Jakubik et al25 suggest that when highconsidered to be held by nurses with longevity quality mentoring exists, it plays a role in nurses’ or experience of 15 longevity in an orga19 or more years. A nization. O’Keefe and Forrester23 note that mentor is usually an Positive mentoring relationships permeate an expert who has been institution as the pool of mentor-mentee pairs Magnet-designated grows; this in turn creates a healthy working in the nursing prohospitals support the environment in which bullying is not tolerated. importance of mentorfession a significant time, is a prototypimentee relationships cal member, and is for positive employee adequately integrated in the group. 20 retention and positive recruitment outcomes. Some hospitals may not spend money on a Mentorship improves nursing proficiency, and as mentoring program because, as a relational process self-confidence increases, new nurses adjust to their that nurtures the whole person, mentoring is not roles more effectively, developing new skills and specific to the types of clinical and management knowledge and becoming prepared to work with 18 skills that must be provided as continuing educaothers. Positive mentoring relationships permeate tion.19 Hospitals and organizations already must an institution as the pool of mentor-mentee pairs grows; this in turn creates a healthy working enbear the cost of training new employees, which can 21 vironment in which bullying is not tolerated. be nearly $75,000 per new employee.12 These costs include advertising, recruiting, subsequent retrainExpert nurses, as mentors, demonstrate the caring ing, and the use of agency or travel nurses. There practices that create the compassionate, supportive, are also the hidden costs of lost productivity and and therapeutic environments patients and perorganizational knowledge.12 Organizational insonnel need. New nurses learn collaboration with patients, their family members, and the health care vestment in nurses’ personal growth and mastery team from the teaching and coaching that mentors is vital to creating and sustaining a perioperative provide. A new nurse may be focused on the task nursing environment that exposes novice nurses to at hand, while a mentor can demonstrate how to new procedures and equipment on a daily basis.18 attend to the task and incorporate patient teaching.22 In these ways, strong mentor-mentee teams MENTORS AS ROLE MODELS improve patient care outcomes.23,24 Furthermore, One of the most important tasks that a mentor in a study of six diverse disciplines, nursing was should undertake is that of a role model. Mentors the only discipline to consider the influence of who serve as role models for new nurses provide an mentoring on improved service delivery to the observable image of imitation, demonstrate skills consumer (ie, the patient).18 This suggests that the and qualities to emulate, and begin to provide new profession recognizes the link among a mentoring nurses with decision-making skills.26 work environment, increased competency, and Communication techniques that mentors who are improved health care outcomes.18 role models can use with mentees include quesMentoring can be viewed from the dyad pertioning, thinking aloud, and debriefing. These spective as a relationship between just the mentor techniques provide a foundation for two truisms 590 j AORN Journal
BULLYING, MENTORING, AND PATIENT CARE that can be applied to mentoring: first, when trying something new, a mentee should not be afraid to ask for help; and second, when a mentee asks a mentor for help, the mentor should be generous and return the favor in kind (ie, mentors should remember that someone once mentored them).23
www.aornjournal.org
mentor should offer to accompany the mentee to provide support.
Debriefing Debriefings are discussion sessions that occur in a group setting, and they should emphasize reflection and learning through open, blameless dialogue. Debriefing with a mentee is helpful after a learning Questioning exercise because it aids in retention of new skills Asking questions allows the mentor not only to and the development of clinical evaluation skills.26 confirm information that is already known but also to allow the mentee to For example, debriefthink through things ing after a simulation on his or her own. This Experienced nurses should engage in positive session provides the type of exchange inmentoring to orient, support, and educate less mentee with an opvolves the use of open experienced nurses in their new roles or careers portunity to verbalize as well as to help nurses love what they do and what went right, beand closed questions not decide to leave the profession. to encourage reflechaviors to retain, and tion, check knowledge, what went wrong (ie, and promote insight. what he or she can As a technique, questioning must occur at the change), thereby facilitating a positive mentoring appropriate time and place. For example, one environment. nursing student related her report of an extremely AUTHENTIC LEADERSHIP upsetting episode in which a clinical instructor The literature suggests that solutions for bullying interrogated her on procedure at the patient’s begin with nursing leaders. Unit culture is a rebedside while the family was present (verbal flection of perioperative leadership. For leadership communication, May 2013). Mentors should to be authentic and effective in establishing a culavoid situations that have the potential to demorture that does not tolerate bullying, leaders must alize learners (eg, requiring mentees to rehearse demonstrate genuine caring and respect for emdecisions in front of patients) and instead choose ployees as well as open and honest dialogue, a setting that is more conducive to learning (eg, especially in the event team members do not meet away from patient or staff areas, such as a confer26 ethical or moral standards of conduct.27 According ence room or computer area). to provision 1.5 of the American Nurses Association Code of Ethics,28 nurses must maintain comThinking Aloud This technique allows the mentor to engage the passionate and caring relationships with colleagues mentee in options, decisions, and debates related as well as a commitment to the fair treatment of to care situations as they unfold. Mentors can use individuals, integrity-preserving compromise, and this type of exchange to promote problem-solving resolution of conflict. Perioperative leaders must be and decision-making skills. A mentor might use able to evaluate the culture of the nursing unit for this method to assess a mentee’s comfort level signs of bullying and take action to enforce cultural with performing aspects of a plan of care. By expectations that support a code of professional asking questions to verbalize a rationale, the conduct.29 To ensure this level of conduct requires mentor can determine whether the mentee is a conscious effort on the part of leaders to recogready to proceed independently or whether the nize bullying, identify contributing factors, and AORN Journal j 591
May 2014
FREDERICK
Vol 99 No 5
develop a plan for change. Weaver9 suggests that interpersonal conflict may be deterred if nurse managers and nurse leaders actively support new graduates in building positive interpersonal relationships with coworkers, physicians, surgeons, and ancillary personnel. STABILIZING THE PROFESSION As a nurse, I understand the frustration of a new nurse, or any nurse, who has been the victim of bullying. Lack of mentoring does not have to be a behavior that defines the nursing profession. Experienced nurses should engage in positive mentoring to orient, support, and educate less experienced nurses in their new roles or careers as well as to help nurses love what they do and not decide to leave the profession. The “they dare to care” and “I’m a nurse” campaigns of Johnson & Johnson30 are reminders of the need to stabilize the nursing workforce. Nurses must make an effort to care about their peers and take ownership of their role in mentoring and promoting a culture of acceptance.29 Perioperative leaders and health care organizations must support interprofessional discussions that will promote collaboration and deter conflict.9 Nursing is a caring profession. Nurses care for patients but also must care for one another. Mentors should receive the education and support they need to advise, coach, counsel, guide, sponsor, teach, role model, and provide resources (eg, write a set of instructions for a piece of equipment with which a new nurse may be unfamiliar). Authentic leadership, honest dialogue, role modeling, and genuinely caring for others are all strong first steps in establishing a culture of mentoring. The nursing profession needs to learn the mentoring process both to fight back against incivility and to maintain a stable workforce. It is through this culture of acceptance and getting along with one another that nursing can become a truly united profession that does not eat its young. Editor’s note: Magnet is a registered trademark of the American Nurses Credentialing Center, Silver Spring, MD.
592 j AORN Journal
References 1. Do nurses eat their young? What’s wrong with communication in health care? Health Communications and Health Advocacy. January 22, 2013. http://kdhhealth comm.wordpress.com/2013/01/22/do-nurses-eat-their -young-whats-wrong-with-communication-in-health -care. Accessed February 7, 2014. 2. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health: Report Recommendations. Washington, DC: The National Academies Press; 2010. http://www.iom.edu/w/media/Files/Report %20Files/2010/The-Future-of-Nursing/Future%20of% 20Nursing%202010%20Recommendations.pdf. Accessed February 3, 2014. 3. Lewis MA. Nurse bullying: organizational considerations in the maintenance and perpetration of health care bullying cultures. J Nurs Manag. 2006;14(1):52-58. 4. Johnson SL, Rea RE. Workplace bullying: concerns for nurse leaders. J Nurs Adm. 2009;39(2):84-90. 5. Hill LA, Sawatzky JA. Transitioning into the nurse practitioner role through mentorship. J Prof Nurs. 2011; 27(3):161-167. 6. The WBI definition of workplace bullying. Workplace Bullying Institute. http://www.workplacebullying.org/ individuals/problem/definition. Accessed February 4, 2014. 7. Hutchinson M, Jackson D, Wilkes L, Vickers MH. A new model of bullying in the nursing workplace: organizational characteristics as critical antecedents. ANS Adv Nurs Sci. 2008;31(2):E60-E71. 8. Rocker CF. Responsibility of a frontline manager regarding staff bullying. Online J Issues Nurs. 2012;17(3):6. 9. Weaver KB. The effects of horizontal violence and bullying on new nurse retention. J Nurses Prof Dev. 2013;29(3):138-142. 10. Egues AL, Leinung EZ. The bully within and without: strategies to address horizontal violence in nursing. Nurs Forum. 2013;48(3):185-190. 11. MacKusick CI, Minick P. Why are nurses leaving? Findings from an initial qualitative study on nursing attrition. Medsurg Nurs. 2010;19(6):335-340. 12. Cottingham S, DiBartolo MC, Battistoni S, Brown T. Partners in nursing: a mentoring initiative to enhance nurse retention. Nurs Educ Perspect. 2011;32(4):250-255. 13. Hayes LJ, O’Brien-Pallas L, Duffield C, et al. Nurse turnover: a literature reviewdan update. Int J Nurs Stud. 2012;49(7):887-905. 14. Nursing shortage. American Association of Colleges of Nursing. January 21, 2014. http://www.aacn.nche.edu/ media-relations/fact-sheets/nursing-shortage. Accessed February 15, 2014. 15. Buerhaus PI, Auerbach DI, Staiger DO. The recent surge in nurse employment: causes and implications. Health Aff (Millwood). 2009;28(4):w657-w668. 16. United States Department of Labor. Economic News Release: Table 6. Employment by major occupational group, 2012 and projected 2022. Bureau of Labor Statistics. http://www.bls.gov/news.release/ecopro.t06.htm. Last modified December 19, 2013. Accessed February 15, 2014.
BULLYING, MENTORING, AND PATIENT CARE 17. Faculty Shortages in Baccalaureate and Graduate Nursing Programs: Scope of the Problem and Strategies for Expanding the Supply [white paper]. Washington, DC: American Association of Colleges of Nursing. http:// www.aacn.nche.edu/publications/white-papers/faculty shortage.pdf. Updated June 2005. Accessed February 16, 2014. 18. Mijares L, Baxley SM, Bond ML. Guiding hands: a concept analysis of mentoring. J Theory Construction Testing. 2013;17(1):23-28. 19. Johnson JE, Billingsley M, Crichlow T, Ferrell E. Professional development for nurses: mentoring along the u-shaped curve. Nurs Adm Q. 2011;35(2):119-125. 20. Topa G, Guglielmi D, Depolo M. Mentoring and group identification as antecedents of satisfaction and health among nurses: what role do bullying experiences play? [published online ahead of print July 27, 2013] Nurse Educ Today. doi: 10.1016/j.nedt.2013.07.006. 21. Wagner AL, Seymour ME. A model of caring mentorship for nursing. J Nurses Staff Dev. 2007;23(5):201-211. 22. Kanaskie ML. Mentoringda staff retention tool. Crit Care Nurs Q. 2006;29(3):248-252. 23. O’Keefe T, Forrester DA. A successful online mentoring program for nurses. Nurse Admin Q. 2009;33(3):245-250. 24. Vessey JA, Demarco R, DiFazio R. Bullying, harassment, and horizontal violence in the nursing workforce: the state of the science. Annu Rev Nurs Res. 2010;28:133-157. 25. Jakubik LD, Eliades AB, Gavriloff CL, Weese MM. Nurse mentoring study demonstrates a magnetic work environment: predictors of mentoring benefits among pediatric nurses. J Pediatr Nurs. 2011;26(2):156-164.
www.aornjournal.org
26. Ness V, Duffy K, McCallum J, Price L. Supporting and mentoring nursing students in practice. Nurs Stand. 2010; 25(1):41-46. 27. Spence Laschinger HK, Wong CA, Grau AL. The influence of authentic leadership on newly graduated nurses’ experiences of workplace bullying, burnout and retention outcomes: a cross-sectional study. Int J Nurs Stud. 2012; 49(10):1266-1276. 28. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Association; 2001. http://www.nursingworld.org/MainMenuCategories/ EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics .pdf. Accessed February 3, 2014. 29. Flateau-Lux LR, Gravel T. Put a stop to bullying new nurses. Nursing. 2013;43(6):24-28. 30. Larson J. Johnson & Johnson kicks off nursing awareness campaign. Nursezone.com. April 2, 2012. http://www .nursezone.com/student-nurses/student-nurses-featured -articles/Johnson-amp-Johnson-Kicks-Off-Nursing-Aware ness-Campaign_18598.aspx. Accessed January 30, 2014.
Dorothea Frederick, MSN, CNOR, is an instructor at Thomas Jefferson University, Philadelphia, PA. Ms Frederick has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 593
ABSTRACT The literature suggests that acts of bullying are a root cause of new nurses leaving their units or the profession entirely and have the potential to worsen the nursing shortage. As an effective way to address bullying in the perioperative setting, mentoring benefits the nursing profession. Mentoring can have a direct influence on nurses’ longevity in a health care organization, thereby strengthening the nursing workforce. Magnet-designated hospitals support the importance of mentor-mentee relationships for positive employee retention and positive recruitment outcomes. One of the most important tasks that a mentor should undertake is that of a role model. Establishing a culture of mentoring requires authentic leadership, genuine caring and respect for employees, and open communication. The entire nursing profession benefits from a culture of mentoring, as do the patients and families who receive care. AORN J 99 (May 2014) 587-593. Ó AORN, Inc, 2014. http:// dx.doi.org/10.1016/j.aorn.2013.10.023 Key words: mentoring, bullying, authentic leadership, longevity, staffing, role modeling, debriefing, professional conduct, Magnet.
B
ullying should not occur in a profession dedicated to caring and compassion,1 and yet “nurses eat their young” is an expression that is familiar to all nurses.2 Estimates suggest that more than 80% of nurses experience bullying at some point in their working lives.3 As a travel nurse who works in the OR, I am aware of the factors that contribute to a changing workforce and the requirement for agency services and travel nurses. I have witnessed nurse-to-nurse bullying, most often between mentors and mentees. For example, I have observed nurses who refuse to mentor, nurses who withhold information, and nurses who simply ignore their mentees. The literature suggests that there is a link between these
behaviors and high rates of employee turnover, incivility, and decreased quality of care.4 Mentoring is an important strategy for addressing bullying in the workplace setting. Mentoring can be defined as an intense relationship between a novice and expert practitioner that promotes role socialization, creates a supportive environment, fills the gap between didactic and real-world experience, and results in ultimate role success of the novice.5(p161) Mentoring cultivates nurse leaders, improves team morale, and retains nurses. The entire nursing profession benefits from a culture of mentoring, as
http://dx.doi.org/10.1016/j.aorn.2013.10.023
Ó AORN, Inc, 2014
May 2014
Vol 99 No 5
AORN Journal j 587
May 2014
Vol 99 No 5
do the patients and families who receive care. According to the 2010 Institute of Medicine report on the future of nursing, mentoring is an effective way to strengthen the nursing workforce and improve the quality of care and patient outcomes.2 This article examines bullying as a key contributor to the instability of the nursing workforce and mentoring as a solution for change. Mentoring allows perioperative teams to respond to bullying in a positive manner and to modify inappropriate behavior. A mentoring culture begins with authentic leadership, genuine caring and respect for employees, and open communication. BULLYING The Workplace Bullying Institute defines workplace bullying as repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators that takes one or more of the following forms: n
verbal abuse; n offensive conduct/behaviors (including nonverbal) [that] are threatening, humiliating, or intimidating; and n work interferencedsabotaged[that] prevents work from getting done.6 Other terms associated with bullying are workplace incivility, horizontal hostility, lateral violence, and hazing. The victim of bullying often is subjected to two or more negative incidents per week during a six-month period.4 The difference between bullying and other types of conflict is a power disparity that exists between the bully and the victim. Behaviors can be subtle and nonaggressive, making it difficult for a victim to prove that he or she is a target of aggression.4 Acts of aggression may include personal attack, attack on reputation or competency, and attack through work tasks.7 Why Nurses Bully Nurses who bully other nurses have been characterized as having high levels of self-interest, a need 588 j AORN Journal
FREDERICK for power, and personal or psychological problems.8 Regarding nurse-to-nurse bullying, the bully is usually an experienced nurse in a mentoring role to a new nurse, who is the victim. Mentors who bully novice nurses show patterns of abuse, such as allowing new nurses to struggle or setting them up to fail and then coming to the rescue of the situation. Consider the following example: A surgeon says a procedure will be short and routine and that electrocautery will not be needed. During the course of the procedure, the situation changes and the surgeon requires electrocautery. The new nurse looks questioningly at her mentor about how to apply the grounding pad to a draped patient, but the mentor offers no suggestions. The mentee does not know what is required, the surgeon gets frustrated with the new nurse, and only then does the experienced nurse intervene. In this scenario, if the mentor had not engaged in bullying behavior, she would have simply given instructive guidance to the new nurse. As a result, the new nurse would have proceeded correctly and been able to control the situation, and the procedure would have gone smoothly. To understand the cause of nurse-to-nurse bullying, Weaver’s analysis9 suggests that nurses who bully are responding to a sense of powerlessness they experience because of the dominant influence of physicians and administrators. For nurses, feelings of powerlessness can lead to feelings of oppression, which can manifest as aggression. According to Weaver,9 nurses who bully are those who feel the power imbalance associated with restricted autonomy and autocratic leadership. In this framework of analysis, nurses respond to feelings of powerlessness and a perceived lack of control through bullying and aggressive behaviors, which negatively affect their clinical practice and professional relationships. Normalization of the bullying behavior occurs when perioperative team members (ie, bystanders) tolerate it as being common to the practice setting.7 The inaction of bystanders, whether out of fear of becoming the next victim, or because the culture does not
BULLYING, MENTORING, AND PATIENT CARE
www.aornjournal.org
support confrontation of the abuse, empowers the bully. 10
of value, lack of professional stimulation, and inadequate support and mentoring.12 In some cases, turnover may be beneficial to facilities in terms Effects of Bullying of reducing costs because of decreased salaries, New nurses are often the victims of bullying. The providing better matches of employees to employknowledge that nurses attain in nursing school is ment, and infusing new knowledge and ideas. Inthe required preparation for clinical practice, but consistencies in nursing turnover definitions and it does not necessarily prepare them for the reality methodology limit the ability to compare turnover of nursing. The fact that new nurses are clinically rates between units and across jurisdictions over untested can be pertime; however, esticeived as an invitation mates suggest that for bullying behavior The inaction of bystanders, whether out of fear nurse turnover will by experienced nurses, of becoming the next victim, or because the reach 50% within the culture does not support confrontation of who feel justified in first three years of abuse, empowers the bully. their harsh treatment clinical practice.13,14 of new graduates Therefore, turnover because their commost likely has nega9 petency is not trusted. Bullying and disretive implications as a threat to the stability of the spectful behaviors from experienced nurses nursing profession.13 toward new graduates have been shown to In the United States, nursing workforce proinhibit new nurses’ learning and growth and jections indicate that the RN shortage may exceed 9 stunt their potential. 500,000 RNs by 2025, according to the American Johnson and Rea4 suggest that bullying behavior Association of Colleges of Nursing.14,15 In 2012, is more predictive of a victim’s intent to leave the the Bureau of Labor Statistics reported data that profession than satisfaction with salary. New nurses project the number of employed nurses will grow not only leave their units to avoid being bullied but from 2.74 million in 2010 to 3.45 million in 2020 potentially leave the profession entirely.9 MacKusick (ie, 712,000 new jobs, or an increase of 26%).16 At and Minick11 relate the following from a new RN a time when health care is expanding, however, practicing for two months on the night shift. estimates suggest that 30% to 50% of all new RNs are at risk of leaving their current jobs within their I was totally alone . . . one patient in what I first three years of practice.11,17 It is critically imthought was SVT [supraventricular tachycardia], portant to address factors that contribute to fewer one pulling out all of his lines because he was nurses being available to provide care or to meet disoriented, and one who really seemed to have staffing needs. Included in these factors are bula hard time breathing. The RNs in the break lying and lack of mentoring. room said they would be there in a minute. I called the supervisor, [who] told me to find my MENTORING AS A SOLUTION mentor. I was all alone, all the time.11(p337) Mentoring encompasses both an emotional and a transitional relationship in which the experienced This new nurse left clinical nursing after one year.9 professional teaches, guides, and serves as a model Bullying behaviors can have an adverse effect for the less experienced person; nurses who care on a victim’s job satisfaction but also on overall and offer wisdom to other nurses are mentoring.18 nursing retention.4 Among the reasons that nurses cite for leaving positions or the profession are lack New OR nurses, as they transition from graduate to of appreciation from superiors, a diminished sense experienced perioperative nurses, are expected to AORN Journal j 589
May 2014
Vol 99 No 5
FREDERICK
function at an advanced level. There is a challenge and the mentee or from the triad perspective as to provide safe and competent care to patients as an organizational phenomenon among the mentee, they continue to fill the gaps in their knowledge. the mentor, and the organization.25 The triad apMentors help them develop advanced clinical skills proach reflects the MagnetÒ philosophy and is along with critical thinking while maintaining consistent with a positive mentoring work envi5 a nursing focus. Organizational knowledge is ronment. Jakubik et al25 suggest that when highconsidered to be held by nurses with longevity quality mentoring exists, it plays a role in nurses’ or experience of 15 longevity in an orga19 or more years. A nization. O’Keefe and Forrester23 note that mentor is usually an Positive mentoring relationships permeate an expert who has been institution as the pool of mentor-mentee pairs Magnet-designated grows; this in turn creates a healthy working in the nursing prohospitals support the environment in which bullying is not tolerated. importance of mentorfession a significant time, is a prototypimentee relationships cal member, and is for positive employee adequately integrated in the group. 20 retention and positive recruitment outcomes. Some hospitals may not spend money on a Mentorship improves nursing proficiency, and as mentoring program because, as a relational process self-confidence increases, new nurses adjust to their that nurtures the whole person, mentoring is not roles more effectively, developing new skills and specific to the types of clinical and management knowledge and becoming prepared to work with 18 skills that must be provided as continuing educaothers. Positive mentoring relationships permeate tion.19 Hospitals and organizations already must an institution as the pool of mentor-mentee pairs grows; this in turn creates a healthy working enbear the cost of training new employees, which can 21 vironment in which bullying is not tolerated. be nearly $75,000 per new employee.12 These costs include advertising, recruiting, subsequent retrainExpert nurses, as mentors, demonstrate the caring ing, and the use of agency or travel nurses. There practices that create the compassionate, supportive, are also the hidden costs of lost productivity and and therapeutic environments patients and perorganizational knowledge.12 Organizational insonnel need. New nurses learn collaboration with patients, their family members, and the health care vestment in nurses’ personal growth and mastery team from the teaching and coaching that mentors is vital to creating and sustaining a perioperative provide. A new nurse may be focused on the task nursing environment that exposes novice nurses to at hand, while a mentor can demonstrate how to new procedures and equipment on a daily basis.18 attend to the task and incorporate patient teaching.22 In these ways, strong mentor-mentee teams MENTORS AS ROLE MODELS improve patient care outcomes.23,24 Furthermore, One of the most important tasks that a mentor in a study of six diverse disciplines, nursing was should undertake is that of a role model. Mentors the only discipline to consider the influence of who serve as role models for new nurses provide an mentoring on improved service delivery to the observable image of imitation, demonstrate skills consumer (ie, the patient).18 This suggests that the and qualities to emulate, and begin to provide new profession recognizes the link among a mentoring nurses with decision-making skills.26 work environment, increased competency, and Communication techniques that mentors who are improved health care outcomes.18 role models can use with mentees include quesMentoring can be viewed from the dyad pertioning, thinking aloud, and debriefing. These spective as a relationship between just the mentor techniques provide a foundation for two truisms 590 j AORN Journal
BULLYING, MENTORING, AND PATIENT CARE that can be applied to mentoring: first, when trying something new, a mentee should not be afraid to ask for help; and second, when a mentee asks a mentor for help, the mentor should be generous and return the favor in kind (ie, mentors should remember that someone once mentored them).23
www.aornjournal.org
mentor should offer to accompany the mentee to provide support.
Debriefing Debriefings are discussion sessions that occur in a group setting, and they should emphasize reflection and learning through open, blameless dialogue. Debriefing with a mentee is helpful after a learning Questioning exercise because it aids in retention of new skills Asking questions allows the mentor not only to and the development of clinical evaluation skills.26 confirm information that is already known but also to allow the mentee to For example, debriefthink through things ing after a simulation on his or her own. This Experienced nurses should engage in positive session provides the type of exchange inmentoring to orient, support, and educate less mentee with an opvolves the use of open experienced nurses in their new roles or careers portunity to verbalize as well as to help nurses love what they do and what went right, beand closed questions not decide to leave the profession. to encourage reflechaviors to retain, and tion, check knowledge, what went wrong (ie, and promote insight. what he or she can As a technique, questioning must occur at the change), thereby facilitating a positive mentoring appropriate time and place. For example, one environment. nursing student related her report of an extremely AUTHENTIC LEADERSHIP upsetting episode in which a clinical instructor The literature suggests that solutions for bullying interrogated her on procedure at the patient’s begin with nursing leaders. Unit culture is a rebedside while the family was present (verbal flection of perioperative leadership. For leadership communication, May 2013). Mentors should to be authentic and effective in establishing a culavoid situations that have the potential to demorture that does not tolerate bullying, leaders must alize learners (eg, requiring mentees to rehearse demonstrate genuine caring and respect for emdecisions in front of patients) and instead choose ployees as well as open and honest dialogue, a setting that is more conducive to learning (eg, especially in the event team members do not meet away from patient or staff areas, such as a confer26 ethical or moral standards of conduct.27 According ence room or computer area). to provision 1.5 of the American Nurses Association Code of Ethics,28 nurses must maintain comThinking Aloud This technique allows the mentor to engage the passionate and caring relationships with colleagues mentee in options, decisions, and debates related as well as a commitment to the fair treatment of to care situations as they unfold. Mentors can use individuals, integrity-preserving compromise, and this type of exchange to promote problem-solving resolution of conflict. Perioperative leaders must be and decision-making skills. A mentor might use able to evaluate the culture of the nursing unit for this method to assess a mentee’s comfort level signs of bullying and take action to enforce cultural with performing aspects of a plan of care. By expectations that support a code of professional asking questions to verbalize a rationale, the conduct.29 To ensure this level of conduct requires mentor can determine whether the mentee is a conscious effort on the part of leaders to recogready to proceed independently or whether the nize bullying, identify contributing factors, and AORN Journal j 591
May 2014
FREDERICK
Vol 99 No 5
develop a plan for change. Weaver9 suggests that interpersonal conflict may be deterred if nurse managers and nurse leaders actively support new graduates in building positive interpersonal relationships with coworkers, physicians, surgeons, and ancillary personnel. STABILIZING THE PROFESSION As a nurse, I understand the frustration of a new nurse, or any nurse, who has been the victim of bullying. Lack of mentoring does not have to be a behavior that defines the nursing profession. Experienced nurses should engage in positive mentoring to orient, support, and educate less experienced nurses in their new roles or careers as well as to help nurses love what they do and not decide to leave the profession. The “they dare to care” and “I’m a nurse” campaigns of Johnson & Johnson30 are reminders of the need to stabilize the nursing workforce. Nurses must make an effort to care about their peers and take ownership of their role in mentoring and promoting a culture of acceptance.29 Perioperative leaders and health care organizations must support interprofessional discussions that will promote collaboration and deter conflict.9 Nursing is a caring profession. Nurses care for patients but also must care for one another. Mentors should receive the education and support they need to advise, coach, counsel, guide, sponsor, teach, role model, and provide resources (eg, write a set of instructions for a piece of equipment with which a new nurse may be unfamiliar). Authentic leadership, honest dialogue, role modeling, and genuinely caring for others are all strong first steps in establishing a culture of mentoring. The nursing profession needs to learn the mentoring process both to fight back against incivility and to maintain a stable workforce. It is through this culture of acceptance and getting along with one another that nursing can become a truly united profession that does not eat its young. Editor’s note: Magnet is a registered trademark of the American Nurses Credentialing Center, Silver Spring, MD.
592 j AORN Journal
References 1. Do nurses eat their young? What’s wrong with communication in health care? Health Communications and Health Advocacy. January 22, 2013. http://kdhhealth comm.wordpress.com/2013/01/22/do-nurses-eat-their -young-whats-wrong-with-communication-in-health -care. Accessed February 7, 2014. 2. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health: Report Recommendations. Washington, DC: The National Academies Press; 2010. http://www.iom.edu/w/media/Files/Report %20Files/2010/The-Future-of-Nursing/Future%20of% 20Nursing%202010%20Recommendations.pdf. Accessed February 3, 2014. 3. Lewis MA. Nurse bullying: organizational considerations in the maintenance and perpetration of health care bullying cultures. J Nurs Manag. 2006;14(1):52-58. 4. Johnson SL, Rea RE. Workplace bullying: concerns for nurse leaders. J Nurs Adm. 2009;39(2):84-90. 5. Hill LA, Sawatzky JA. Transitioning into the nurse practitioner role through mentorship. J Prof Nurs. 2011; 27(3):161-167. 6. The WBI definition of workplace bullying. Workplace Bullying Institute. http://www.workplacebullying.org/ individuals/problem/definition. Accessed February 4, 2014. 7. Hutchinson M, Jackson D, Wilkes L, Vickers MH. A new model of bullying in the nursing workplace: organizational characteristics as critical antecedents. ANS Adv Nurs Sci. 2008;31(2):E60-E71. 8. Rocker CF. Responsibility of a frontline manager regarding staff bullying. Online J Issues Nurs. 2012;17(3):6. 9. Weaver KB. The effects of horizontal violence and bullying on new nurse retention. J Nurses Prof Dev. 2013;29(3):138-142. 10. Egues AL, Leinung EZ. The bully within and without: strategies to address horizontal violence in nursing. Nurs Forum. 2013;48(3):185-190. 11. MacKusick CI, Minick P. Why are nurses leaving? Findings from an initial qualitative study on nursing attrition. Medsurg Nurs. 2010;19(6):335-340. 12. Cottingham S, DiBartolo MC, Battistoni S, Brown T. Partners in nursing: a mentoring initiative to enhance nurse retention. Nurs Educ Perspect. 2011;32(4):250-255. 13. Hayes LJ, O’Brien-Pallas L, Duffield C, et al. Nurse turnover: a literature reviewdan update. Int J Nurs Stud. 2012;49(7):887-905. 14. Nursing shortage. American Association of Colleges of Nursing. January 21, 2014. http://www.aacn.nche.edu/ media-relations/fact-sheets/nursing-shortage. Accessed February 15, 2014. 15. Buerhaus PI, Auerbach DI, Staiger DO. The recent surge in nurse employment: causes and implications. Health Aff (Millwood). 2009;28(4):w657-w668. 16. United States Department of Labor. Economic News Release: Table 6. Employment by major occupational group, 2012 and projected 2022. Bureau of Labor Statistics. http://www.bls.gov/news.release/ecopro.t06.htm. Last modified December 19, 2013. Accessed February 15, 2014.
BULLYING, MENTORING, AND PATIENT CARE 17. Faculty Shortages in Baccalaureate and Graduate Nursing Programs: Scope of the Problem and Strategies for Expanding the Supply [white paper]. Washington, DC: American Association of Colleges of Nursing. http:// www.aacn.nche.edu/publications/white-papers/faculty shortage.pdf. Updated June 2005. Accessed February 16, 2014. 18. Mijares L, Baxley SM, Bond ML. Guiding hands: a concept analysis of mentoring. J Theory Construction Testing. 2013;17(1):23-28. 19. Johnson JE, Billingsley M, Crichlow T, Ferrell E. Professional development for nurses: mentoring along the u-shaped curve. Nurs Adm Q. 2011;35(2):119-125. 20. Topa G, Guglielmi D, Depolo M. Mentoring and group identification as antecedents of satisfaction and health among nurses: what role do bullying experiences play? [published online ahead of print July 27, 2013] Nurse Educ Today. doi: 10.1016/j.nedt.2013.07.006. 21. Wagner AL, Seymour ME. A model of caring mentorship for nursing. J Nurses Staff Dev. 2007;23(5):201-211. 22. Kanaskie ML. Mentoringda staff retention tool. Crit Care Nurs Q. 2006;29(3):248-252. 23. O’Keefe T, Forrester DA. A successful online mentoring program for nurses. Nurse Admin Q. 2009;33(3):245-250. 24. Vessey JA, Demarco R, DiFazio R. Bullying, harassment, and horizontal violence in the nursing workforce: the state of the science. Annu Rev Nurs Res. 2010;28:133-157. 25. Jakubik LD, Eliades AB, Gavriloff CL, Weese MM. Nurse mentoring study demonstrates a magnetic work environment: predictors of mentoring benefits among pediatric nurses. J Pediatr Nurs. 2011;26(2):156-164.
www.aornjournal.org
26. Ness V, Duffy K, McCallum J, Price L. Supporting and mentoring nursing students in practice. Nurs Stand. 2010; 25(1):41-46. 27. Spence Laschinger HK, Wong CA, Grau AL. The influence of authentic leadership on newly graduated nurses’ experiences of workplace bullying, burnout and retention outcomes: a cross-sectional study. Int J Nurs Stud. 2012; 49(10):1266-1276. 28. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Association; 2001. http://www.nursingworld.org/MainMenuCategories/ EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics .pdf. Accessed February 3, 2014. 29. Flateau-Lux LR, Gravel T. Put a stop to bullying new nurses. Nursing. 2013;43(6):24-28. 30. Larson J. Johnson & Johnson kicks off nursing awareness campaign. Nursezone.com. April 2, 2012. http://www .nursezone.com/student-nurses/student-nurses-featured -articles/Johnson-amp-Johnson-Kicks-Off-Nursing-Aware ness-Campaign_18598.aspx. Accessed January 30, 2014.
Dorothea Frederick, MSN, CNOR, is an instructor at Thomas Jefferson University, Philadelphia, PA. Ms Frederick has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 593
