By BETSY TAYLOR
Operating room nurse Kellee Schwieger recalls a day at work when one nurse, angry at a co-worker, verbally vowed to do everything possible to irritate the other nurse at work that day.
Jackie Nelson, left, mentors her nursing colleague Kalee Jensen in the CHI Health St. Francis emergency room in Grand Island, Neb. Nelson is working to formalize a nurse mentoring program to guide newer nurses at the hospital, just one way the hospital is improving the workplace culture.
Photo by Andrew Carpenean
She's seen nurses get incensed at others who prepare for surgery in a different manner than they do, rudely taking a nurse to task or gossiping if one nurse deviates from the way an experienced hand wants things to be done. Some nurses have withheld information about a surgeon's preferences in an operating room from other nurses, just so those in the know appear more responsive to the physician's needs during surgery.
Even with 35 years of experience, Schwieger used to worry about what she'd face in a work day — not because of the potential for unexpected complications in medical cases, but because of the unpredictable behavior from some colleagues. "You might be walking on eggshells; you don't know if someone will be nice or if they'll bite your head off."
Lateral violence
Schwieger said the nurse bullying was employee against employee, not nurse against patients. She noted she always stood up for the needs of patients with other staff, even on occasions when she wasn't always comfortable standing up for herself in the workplace.
Organizations like the American Nurses Association and nursing publications frequently have explored the dynamic of bullying between nurses. It often involves more experienced nurses snapping at or demeaning newer nurses. In the industry it's known as lateral violence or horizontal violence — disruptive and inappropriate behavior by an employee to another in an equal or lesser position.
CHI Health St. Francis, the 159-bed hospital in Grand Island, Neb., where Schwieger works, set out three years ago to openly tackle the problem of nurses bullying their peers. The hospital surveyed nurses and technicians about their workplace experiences; it brought in a licensed mental health counselor to address workplace issues related to trust, respect and communication; and it stepped up efforts to mentor new nurses and to give each nursing unit a voice in decision-making. Those efforts have greatly improved the work environment, Schwieger said.
Authentic change
When Beth Bartlett began as St. Francis' chief nursing officer in 2014, part of her work involved preparing the hospital to pursue Magnet designation, work that is still ongoing. The American Nurses Credentialing Center award recognizes hospitals that meet its criteria for high-quality nursing. Bartlett also manages patient care services. As she talked to nursing staff and reviewed the hospital's National Database of Nursing Quality Indicators survey results related to nurse engagement and job satisfaction (see sidebar), she rallied support to begin improving the hospital's culture for nursing staff.
Plenty of nursing journals examine the workplace dynamic of bullying between nurses. "They didn't really say what people were doing about it," Bartlett said.
The hospital brought in Anna Hain, a licensed mental health practitioner who owns Kearney, Neb.-based Blue Water Counseling and Consulting, to educate staff on ways to curb and prevent nurse bullying. Hain, who has a master's in clinical mental health, was a known entity at the hospital and well-respected; she had previously directed the hospital's employee assistance program under the employ of an outside contractor.
Surgery nurse Kellee Schwieger, left, reviews a patient's chart with Beth Bartlett, vice president for patient care services, in a pre-operation bay at CHI Health St. Francis in Grand Island, Neb. Schwieger says the workplace culture has improved after Bartlett and others made it a priority to eliminate nurse bullying.
Photo by Andrew Carpenean
Hain focused her efforts on the surgery department, including the operating room nurses and technicians commonly called scrub techs. These professionals must perform to exacting standards at a fast pace, sometimes under pressure-cooker conditions.
Hain worked with nurses and operating room technicians on building trust and relationships, improving employees' self-awareness of their strengths and weaknesses in the workplace. She conducted assessments to gauge their motivation to change problematic behaviors and educated administrators about how to hold employees accountable for meeting the hospital's standards of conduct. (Bartlett said hospital-wide any concern that could affect safety or patient care — such as a nurse saying another didn't respond when she needed help with a patient — always had been swiftly addressed by managers.)
Hain said nurses may engage in bullying behavior out of frustration if they feel their input is not valued and they are powerless to enact change.
Nurses who don't know how to be direct and clear in conversation may default to passive aggressive behavior. With their emphasis on caring for others, nurses may not focus enough energy on taking care of themselves. Without self-care, they may grow inpatient or experience burnout, and take that out on those around them, Hain said.
Listening to nurses
Hain met Bartlett, two nursing supervisors and a nursing director in January of 2016 to set priorities for changing the culture of the surgery department. Hain said, "One thing they identified was a low level of trust within the department." She visited the hospital from February of 2016 to February of 2017, working with employees in groups and individually.
Hain
She taught stress management and listened to employees' concerns — including lots of talk from them about workplace bullying. "If I heard something again and again — OK, that's something to look into." She took note of patterns of behavior. She identified areas where employees thought the culture needed to improve, and she made recommendations to bring about sought-after changes.
For several years the hospital has had nurse councils to give nurses a voice in decisions related to research, education, quality of care and professional practices. Around the time of the work to improve the hospital's culture for nurses, nurses began an umbrella coordinating council, with an elected nurse president, to share information among nursing units in the hospital. A governance system that supports shared leadership and nurse participation in decision-making is a prerequisite to seeking Magnet status.
As Hain's work progressed, the coordinating council drafted a code of conduct for employees to sign, outlining the behavior expected of operating room nurses and technicians. Hain said she met with operating room supervisors, to review how they looked into concerns raised by staff and how they worked to resolve them, including conflict resolution or disciplinary action.
The effort raised bullying awareness beyond the operating rooms. Nurses hospital-wide wore pins that read: Bully Free Starts with Me during National Bullying Prevention Month in October. Nurses agreed on a code word — goldfish — they could use in conversation with one another in front of other staff or members of the public to signal to the other nurse the need to be mindful of how words or actions were being perceived as aggressive or hurtful.
Bridging generations
Other efforts at the hospital involved educating nurses about differing expectations and communication styles between nurses from the Baby Boomer generation and Millennials. The Baby Boomers might have felt they were thrown into the deep end in their first nursing jobs, and expect young nurses to be forged under similar conditions. Millennials, accustomed to positive reinforcement from parents and schools and instant communication through texting or social media channels, sometimes were frustrated by the hard-nosed treatment, or what they perceived as a dearth of communication between them and the more experienced nurses.
While new nurses do work with a preceptor, in some cases they also are paired with an experienced nurse mentor these days. Emergency department nurse Jackie Nelson is working to formalize a nurse mentoring program that gives less experienced nurses another trusted person they can turn to for practical guidance.
Schwieger said that in the past experienced nurses may have shown little tolerance when a new nurse set up a surgical tray in a way that departed from the hospital's usual practice. Nowadays though, with improved awareness and communication, that difference of opinion can lead to a reevaluation and tweaking of protocols, to everyone's benefit.
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When barbs stop, job satisfaction improves
 Efforts to create a more supportive culture among the nursing staff at CHI Health St. Francis seem to be bearing fruit.
To evaluate whether nurse anti-bullying efforts are having an impact, the hospital's nursing research council used two survey instruments. The first measurement evaluated responses to questions on the National Database of Nursing Quality Indicators survey related to nurse job satisfaction. The second survey instrument is a council-designed observational perception survey measuring horizontal violence, defined as disruptive and inappropriate behavior by an employee to another in an equal or lesser position.
Responses to the nursing quality indicator survey in 2015 showed an improved sense of dignity and respect among St. Francis nurses as compared to the prior year. For a time in 2014, the hospital was out of the Blue Cross Blue Shield provider network, and the nurse council posited that this affected relationships with physicians and community members sufficiently to be a negative drag on nurse job satisfaction, with fewer nurses saying they would recommend St. Francis as a place of employment in 2014 than in 2013. There was a positive uptick on the responses to this question in 2015.
The council found a marked improvement in every category of the National Database of Nursing Quality Indicators scores between 2015 and 2016, with every nursing unit at the hospital outperforming the national mean in every job satisfaction category tracked.
The observational perception survey asks respondents about overt aggression such as verbal threats and belittling, and their personal responses such as not speaking up for fear of retaliation, or looking for another job.
The survey found there was initially an increase in horizontal violence from 2014 to 2015. The nurse council attributed this to heightened awareness of horizontal violence due to education about workplace bullying. There was a decrease in observations and perceptions of horizontal violence at the hospital from 2015 to 2016.
The analysis found fewer reports of overt workplace bullying including verbal threats, negative comments and belittling as well as a decrease in related personal behaviors, such as not speaking up about something or asking for help for fear of retaliation. Survey respondents also reported experiencing an increase in dignity and respect in the workplace.
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