Bully or Bullying? Why Language Matters in Stopping Disruptive Behavior among Nurses & Doctors

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by Beth Boynton, RN, MS

At a recent conference I was talking with a colleague about workplace violence.  She was adamant in her opinion that, “Psychological bullies must be terminated”.  I was and am uneasy about this statement.  If/when other interventions fail, I agree with her, but I don’t believe that such a black and white solution is the best way to begin problem-solving an issue that has so much gray.  In fact, focusing blame on individuals in the early stages of addressing disruptive behavior may allow us to avoid the systemic aspects of this multi-layered problem.

When it comes to horizontal and vertical violence, we are like the frogs in the boiling frog story.  Do you know the one?  The temperature is turned up so slowly that the frog gets used to it until it is too hot to react. Many disruptive behaviors on the part of doctors, nurses and others have been going on for a long time.   We’ve grown accustomed to poor conduct!  Yelling, humiliating, excluding and talking about others behind their backs are common behaviors.  That doesn’t make them O.K., but it does shed light on the necessity of changing the cultures we work in.

As we work to establish and maintain safe cultures and respectful workplaces, there are three reasons for using terminology that includes individual and organizational behaviors.  Each of these will help to reduce resistance, fear, and confusion about zero tolerance for abuse.

1.  Reveals the True Problem

When we use the term ‘bully’ it allows us to blame one person.  ‘Bullying’, on the other hand invites us to consider victims, bystanders and culture.  Since all of these are part of the history and cause of workplace violence, it makes sense to understand and address these aspects of the problem.

A bully can’t exist without a victim or in an environment that doesn’t tolerate bullying behaviors.

2.  Reflection Process is Safer

Looking inward is often a difficult process for many of us and yet an integral part of changing behavior.  Consider how these  reflective questions might feel:

I wonder if I am bullying the new nurse?

I wonder if my behaviors could be perceived as bullying?

I wonder if I am a bully?

The first and second statements allow us to be human and imperfect and include another person’s perception as part of the picture.  The third one is more threatening and defines the very core of our being.  If we are going to change these dynamics, doesn’t it make sense that we give ourselves and each other permission to make mistakes?

In so many of our stressful environments, we have to be quick and accurate.  A seasoned nurse’s decisive comment and action may be excluding and humiliating to a newer nurse.  Our chronic sense of urgency becomes a license for poor conduct.

I know that I have been short-tempered, impatient or frustrated at work. With over 25 years as a nurse, I have rolled my eyes, smirked, or used unfriendly body language.  I have also joined in conversations about other professionals behind their backs.  At this point in my life and career, even with all the work I have done in communication and emotional intelligence, I am not a perfect communicator. However, I am more able to own my part of a conflict and respect how other’s may be impacted, work to modify my behavior, apologize and forgive myself and others.

3.  Bridges to Healing Conversations

As we become safer and more skilled in our reflection process, we will automatically be more prepared to show ownership in a conflict.  This is one of the most powerful factors that leads us to productive conflict rather than remaining stuck in a power struggle.  It is part of the dance of speaking up assertively and listening respectfully that I am often referring to.

An example might be a new OR nurse who is upset and fighting tears because her preceptor humiliated her in front of the team.

The preceptor who perpetuates the status quo might say:

You are going to have to develop a thick skin if you are going to make it as an OR nurse.

The preceptor who is committed to building a more positive workplace might say:

I think I was pretty rough on you this morning.  I could have given you feedback on your set-up without the condescending tone and language I used.  What thoughts do you have?

The second example is a great way to build a respectful and collaborative relationship which we know will contribute to safer, more cost-effective care and long-term rewarding careers.

More insight and many resources regarding poor conduct in healthcare and it’s relationship to quality and safety can be found in The Joint Commission’s Sentinel Event Alert,  Issue 40:  Behaviors that undermine a culture of safety.

You may also find the work of Suffolk Law Professor, David Yamada who hosts a blog called Minding the Workplace and is leading legislative efforts to address workplace bullying to be interesting as well as that of Drs Ruth and Gary Namie, founders of the Workplace Bullying Institute.

Ultimately, as those of us who work in healthcare address disruptive behaviors that arise from stress, lack of awareness, inadequate communication skills, and toxic organizational cultures  we will filter out the few remaining individuals who persist in bullying behavior despite feedback and learning opportunities.  These are the bullies and yes, they should be terminated!

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  • Doris Edwards

    Appreciate this thoughtful discussion. I am impressed by the growing body of scholarship on this complex, significant and pervasive .issue. Cindy Clark at Boise State work uses the term “civility.” The common denominator among solutions is EDUCATION….at the workplace, at conferences, in formal degree work and on the internet. Key points in education are the bolstering of the individual’s sense of self worth, the reinvention of the workplace culture and the development of language with which to communicate. Kudos to all of you who are saying no to bad behavior and teaching others how to say no too.

    • Beth Boynton

      Hi Doris,
      Thanks for your insights. EDUCATION in all it’s forms and venues IS the way!
      Do you have any particular links to Cindy Clark’s work? Or contact info? I’d love to know more about her work. Post here or email me at: beth@bethboynton.com

      I did a book review recently on a related topic: Book Review: The Real Healthcare Reform: How Embracing Civility Can Beat Back Burnout & Revive Your Healthcare Career

      All of this is exciting progress. I just had breakfast yesterday with a friend who is an admin asst in a doctor’s office. She was telling me how she did not accept inappropriate behavior from one of the docs and how she helped a new MA deal with him. I think her teaching is wonderful and may be invisible to upper management, but the rippling effect, I believe will help staff, patients and the organization provide safer care and healthier work lives!

      Thanks for taking the time to post,
      Beth

  • http://www.linkedin.com/pub/peggy-berry/8/989/904 Peggy Berry

    Promoting a culture of pyschological and physical safety inclusive of all healthcare workers with evolve over time. Healthcare workers are the most valuable asset in the healthcare industry. I believe we are trying to raise all healthcare workers’ expectations of that they not only deserve this type of safe environment, which in the past allowed abuse by physicians , patients, families, and visitors and each other, but it requires an open system to reporting of unsafe environments and crucial and respectful conversations with any person exhibiting negative behaviors. We need to report incidents instead of keeping them to ourself or telling friends and stopping there. Only then will the environment be pyschologically and physically safe.

    • Beth Boynton

      Hi Peggy,
      Thanks for your comment. I think you are right about the importance of evolution of safe workplaces over time. It is a ‘sea change’ and no quick fixes. You also raise key points about raising our expectations…We do deserve healthy, safe workplaces, reasonable workloads, respectful leadership, etc etc. In my per diem role as an RN, I work with awesome nurses and aides that may accept a negative status quo because of the reasons you suggest and/or feel hopeless about changing things.

      I guess those of us on the edge of change push things forward bit by bit. Things ARE changing bit by bit!

      And I so agree about safe environments for reporting. They are so vital. Did you happen to read my post: Why Hospitals Should Adopt a “No Innocent Bystander” Rule for Zero Tolerance of Workplace Violence & Promoting Safe Culture

      Take care
      beth

  • http://OurBullyPulpit.org Beverly Peterson

    Really insightful article. Personally I’m very interested in programs that focus on creating respectful workplaces as a way to combat bullying. I wonder if it isn’t a better approach to also take the word “bullying” out of the equation to avoid adversarial situations. It’s the “bully” part of the word that carries so much baggage – especially now. Your questions could just as easily read:
    I wonder if/why I’m singling out the new nurse?
    I wonder if my behaviors could be perceived as abusive/over the top?
    Have I done this before? If so, I wonder why
    Looking forward to reading more of your articles

    • Beth Boynton

      Excellent point, Beverly. I think these are great alternative statements and help to demonstrate an opportunity for creatively applying the concept while utilizing the most helpful language for a particular group. In some organizations or units, taking the word “bully” out of the discussion may help make the environment safe. It is a judgement call, I think. Some may find the word “abusive” to be more offensive and prefer to utilize the “over the top” option you suggest. Ultimately, having these conversations, listening to each others’ perspectives and being willing to work at being respectful of others’ needs is the dance that will lead us to healthy dynamics at work and in schools.

      You might enjoy this related article: Disruptive Behavior, Bullying, Incivility-Workplace Abuse: A Glossary of Violence

      Also, I noticed you are doing some vital work in this area including a petition to President Obama. I signed it and look forward to following your work.
      Take care,
      Beth

  • Amanda R. Todd RN, BS

    Thank you Beth for your intelligent remarks on this subject. There really are responsibilities for all in terms of awareness, accountability, and teaching. You mention ‘the dance speaking up assertively and listening respectfully’: limp dance partners contribute to the problem by withholding valuable feedback. A Kind remark that raises awareness about how behaviors come across can make a positive influence. On the other hand, labeling, demanding perfection, and villifying targeted individuals is more about censorhip than making a contribution to a healthy culture.
    “identify the behaviors bullying; if we label offenders and we have lost the fight for growth and our own objectivity” Amanda R. Todd 4/2011

    • Beth Boynton

      Hi Amanda,
      Nicely put! I so agree that “There really are responsibilities for all in terms of awareness, accountability, and teaching”.
      And censorship, in my opinion is the exact opposite of what we need to be doing! Of course, respectful dialogues are key!

      When I went to grad school I studied organizational development, group dynamics and emotional intelligence. At the time, I thought I was leaving healthcare…(running away screaming may be a better way to put it). I was very interested learning about and teaching related skills and awarenesses to children. I became familiar with the systemic aspects of bullying in schools and see so much application in healthcare. You might enjoy this post re: “No Innocent Bystanders” as it speaks directly to your comment!

      I look forward to more of your insights and again, thank you for your participation.

      Take care,
      Beth

    • Beth Boynton

      Hi Amanda,

      Thanks for sharing your insights. I think your comments offer profound wisdom: “identify the behaviors bullying; if we label offenders and we have lost the fight for growth and our own objectivity”! I notice a date next to the quote- 4/2011. Did you write an article about the topic? If so, please share a link.

      Thanks,
      Beth

  • http://www.manage2001.com Jim Murphy

    Another very helpful post! Your emphasis on the organizational culture is particularly important. Like sexual harassment, bullying is certainly grounds for termination. But just firing people is does not solve the problem and sometimes just sends it to another place, as after all most people who lose their job get another one.

    Naturally bullying and harassment should not be tolerated, but it is even more important to create a culture in which they do not occur. Hiring won’t be perfect, people sometimes change for the worse, and (as Beth is perhaps one the few writers on this topic to point out) we may all have a little bullying inside of us. But such tendencies can be checked if the organizational has a culture in which respectful and honest communication is the norm.

    As Gary’s comment suggests, anti-bullying may have become almost faddish. Efforts on particular improving causes, whether harassment or Six Sigma, should be encouraged and may very well do good. But sometimes it seems that organizations will jump on any bandwagon instead of focusing on the basic needs for success: empowerment, open honest communication, and learning.

    Finally, I cannot resist pointing out that the boiling frog story was discredited many years ago by the Fast Company Consultant Debunking Unit: http://www.fastcompany.com/magazine/01/frog.html . I hope it is not bullying to object to such canards!

    • Beth Boynton

      Hi Jim,
      I’m glad to be corrected re: The Boiling Frog story! I use the metaphor a lot, and will be much more careful about it. A great example of constructive feedback being helpful! Thank you.

      Sometimes, I think, at least in healthcare, “we” look for models that others have had success with such as Six Sigma. It makes sense on some level and yet if the ‘bullying process’ doesn’t get addressed fully, it may not always work. As a group process consultant, I have always been fascinated by the value of engaging stakeholders and inviting input from them. It is much less an intellectual process than it is one which honors the basic needs for success you refer to: “empowerment, open honest communication, and learning”. All of this stuff involves human behavior and solutions inherently require participation of stakeholders.

      For example, I was recently facilitating a breakfast discussion called “Dealing w/ Bullying in the Workplace” at the annual conference for “Ambulatory Surgery Centers Association”. It was an incredibly dynamic conversation although not a lot of intellectual learning. Nurses’ voices, have for a long time, been dismissed or ignored and creating space for this is so important, (not to get stuck in it, but to honor it and move on).

      An organizational development colleague once mentioned to me that her clients did not want “a room full of angry nurses”! I winced. I don’t blame them, and yet avoiding keeps us stuck.

      Thanks again for your comments and correction! :)
      Beth

  • http://workplacebullying.org Gary Namie

    Couldn’t agree more. Publishers of both of our books insisted on Bully despite neither book being about individuals. Instead, it’s bullying the process — lateral violence — that nurses all too often accept as inevitable occupational hazard.

    The self-reflection step is brilliant, albeit rare among abusive individuals.

    Health care providers deserve healthy workplaces. At the very least, non-abusive ones.

    Thank you for your important compassionate work.

    • Beth Boynton

      Thanks, Gary.

      The ‘bullying process’ is a great frame.

      In nursing we are so busy we don’t have time to focus on communication practice, teambuilding and conflict and I believe this is contributing to the persistence of medical errors attributed to ‘human factors’ that we see year after year after year in “Sentinel Event” Statistics. There is always something more urgent to focus on.

      I appreciate your comment re: reflection, too. Perhaps it is another way to eventually (in the course of addressing the ‘bullying process’) to filter out people who can and will do the work to be respectful teamplayers, leaders, followers etc.

      Like Jim Murphy suggests, some of simplest solutions remain illusive.

      Thank you for all of your work to and that of Workplace Bullying Institute. If you’d ever like me to review one of your books on my blog just send a copy to me at P.O. Box 192, Portsmouth, NH. I’m happy to send you a copy of mine if interested.

      Take care,
      Beth