An exploration of bullying behaviours in nursing: a review of the literature

In the UK professional standards that nurses and midwives must uphold are set by the Nursing and Midwifery Council (NMC). These standards are detailed in The Code: Professional standards of practice and behaviour for nurses and midwives (NMC, 2015), which contains a section on working cooperatively, stating that nurses should respect both the expertise and contributions of colleagues, maintain effective communication, keep them informed when sharing the care of patients and be supportive of colleagues who may be experiencing health- or performance-related problems. Following the results of a survey showing bullying behaviours were experienced by 10% of staff in the NHS, guidance was issued to employers in 2006 that all NHS organisations should have bullying and harassment policies in place (NHS Confederation, 2006).

Incidence of bullying 

Workplace bullying has been recognised as a serious issue affecting nurses (Murray, 2009; Roberts et al, 2009; Rodwell and Demir, 2012).

A study in the UK by Quince (2001) resulted in reports from 44% of the 1100 respondents that they had experienced bullying behaviours during the previous year. Carter et al (2013) received 2950 responses to questionnaires from healthcare staff in seven NHS trusts in the north east of England concerning the prevalence and impact of bullying on healthcare staff. This study involved a range of healthcare staff of which more than 600 were nurses; of these 20% had experienced bullying, with over 40% reporting they had witnessed the bullying of other staff in their workplace.

These figures demonstrate that bullying behaviours are prevalent among nursing staff and also other healthcare staff in a range of countries and settings.

Bullying behaviours 

A range of behaviours have been identified as being present in bullying and these can vary in their frequency and intensity.

The most common bullying behaviours include:

• Having opinions and views ignored
• Colleagues withholding information that affects their performance
• Being given tasks with unreasonable or impossible targets or deadlines
• Being humiliated or ridiculed in their work
• Having key areas of responsibility removed and replaced with more trivial or unpleasant tasks

Other forms of bullying identified were:

• The ‘moving of goalposts’ in a person's work without informing them of the changes (Quine, 2001)
• Staff being manipulated into taking on roles and tasks that were not in their best interests
• Having all their decisions systematically challenged
• Given confusing and inaccurate information
• Deliberately informed tasks were urgent when they were not (Cahu et al, 2014)

Other activities reported were:

• Preventing access to telephones and computer terminals
• Aggressive behaviours, such as shouting at the staff member, and threatening them with physical harm

Bullying can go unreported as a result of not being recognised. They found that bullying can initially be viewed as rude behaviour and ignored, and it is not until it develops into more overt and deliberate destructive actions that it is recognised and acknowledged as bullying. Moore et al (2013) suggested that in some work settings disruptive relationships among nurses are the norm and therefore not recognised as something that needs to be challenged.

Perpetrators and targets of bullying 

Although bullying can be carried out by people at the same level in the organisation, the two main groups of nurses identified from the literature as the main perpetrators are those in management positions senior to the person being bullied (Hoel and Cooper, 2000; Moore et al, 2013) and nurses who are established staff members of a particular ward or healthcare setting (Baltimore, 2006; Sauer, 2012).

• Yildirim (2009) examined the connection between workplace bullying and the age, workload, and years of experience in nursing. This study found that work overload contributed to bullying behaviours; however, there was no correlation found between the number of years nurses had been working in the profession and bullying behaviours.
• Quince (2001) found that nurses were more likely to be bullied than any other health professionals.
• Wilkins (2014) reported most bullying as being same gender and more prevalent in workplaces where one gender is dominant.

Causes of bullying 

It has been reported that the culture of the organisation, including hierarchical management and employees not feeling empowered, contributed to bullying behaviours.

• Szutenbach (2009) identified that bullying is learned behaviour with mentors and preceptors bullying students and newly qualified nurses, socialising them into the expectation that they will become bullies themselves towards their colleagues (Randle, 2003; Curtis et al, 2007).
• Wilkins (2014) identified that bullying behaviours often begin early in student nurses' careers when they experience bullying from fellow students.
• Baltimore (2006) indicates that the root of bullying in nursing starts in the university where some nursing lecturers abuse their power and flourish through feelings of superiority, controlling both more junior staff members and students.
• Baltimore continues that many of these people are not self-aware and if their behaviour is pointed out, describe themselves as assertive or passionate. This leads to the continuation of bullying in universities, resulting in nurses accepting that this behaviour is the norm.

Impact of bullying 

Burnes and Pope (2007) identified that those bullied felt isolated, insecure, fearful, and not valued. They also felt powerless, undermined and vulnerable. These responses were supported by Sauer (2012), who also identified that bullying can result in staff not only leaving their jobs but also leaving the profession. Bullying also has an effect on the functioning of the organisation. Burnes and Pope (2007) found that over 30% of those bullied withdrew from certain tasks in their workplace, reduced their commitment to work and many reduced the time they spent at work in order to avoid contact with the bully. Patients can be affected in that it becomes an unsafe environment for patient care (Sousa, 2012). A person who is bullied can feel incompetent and incapable in their work, get flustered and as a result errors may occur, putting the patient at risk. 

• Carter et al (2013)found that several participants who were bullied reported their performance being impaired as they were unable to think clearly and concentrate on procedures and tasks they were undertaking for patients.
• Hesketh et al (2003) found bullied staff were more frequently involved in adverse events such as medication errors and patient injuries due to falls than other staff.
• Burnes and Pope (2007) identified that nurses who were bullied had reduced levels of motivation and commitment to their work, with increased amounts of absence resulting in reduced staffing levels in their places of work.

Actions and interventions to combat bullying 

An important first step in dealing with bullying is for the individual to recognise and admit that they are being bullied (Murray, 2009). The recipient may not initially recognise what is happening as this behaviour may be common in their place of work and accepted as the norm. They may be told by peers or managers that they are over-sensitive, experiencing a personality clash or a different type of management style. Burnes and Pope (2007) identified that one of the main obstacles to tackling bullying is that those who should be responsible for preventing or stopping these behaviours are the ones most likely to be the perpetrators. In Quine’s (2001) study nearly 70% of those bullied had tried to take action to stop the bullying, but only 22% were satisfied with the result of this action. A contributing factor to the continuance of bullying is that co-workers do not intervene even when they are aware that a colleague is being bullied.

Becher and Visovsky (2012) stress the importance of nurse managers modelling good professional behaviours and being supportive and constructive with their staff. This includes staff treating each other with respect, enhancing communication, bringing any conflicts into the open and dealing with them promptly.

Hope. In combatting bullying the concept of hope was identified as a strength by Wilkins (2014). This research found that nurses with high levels of hope took action and felt positive that a bullying situation would be resolved. 

Humour and optimism. Nurses with this outlook approached bullying from a positive perspective conducive to the seeking of possible solutions to the problem. Staff with a pessimistic outlook had limited coping strategies and did not find it easy to identify possible solutions to their situation.

Keeping a record of when and in what form the bullying occurs is vital to provide evidence of what has happened, along with details of any witnesses to events. All NHS organisations are required to have a policy in place to deal with bullying and harassment in the workplace that staff can access and follow to report this behaviour NHS Confederation, 2006).