When nurses hurt nurses

Since I get some hits from Singapore and Canada regarding nursing (e.g. search on the "Nursing in Singapore" blog category or Goggle for "IEN SEC"), I would like to share about relational aggression in nursing and an article on how to deal with bullies in the workplace.

I have recently finished reading a book, "When nurses hurt nurses - Recognizing and Overcoming the Cycle of Bullying" by Cheryl Dellasega. IMHO, it gives a good overview of relational aggression that was (and still is) so commonplace in nursing (especially in Singapore) such that it contributes to common refrains like "nurses eat their young".

About the author: Cheryl Dellasega, PhD, CRNP, works clinically as a nurse practitioner and researches extensively on relational aggression. Her published books include "Surviving Ophelia" and "Mean Girls Grown Up".

IMHO, ultimately the patients suffer when relational aggression in nursing is not addressed. At least in B.C., Canada, there are laws and organizations (e.g. nurses union) that push for and support policy changes to reduce systemic factors. In Singapore, with labour policies that supports discrimination and suppression of labour rights, one can't help but to ask, "What has changed? What will change?" My hopes are not high.

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[Extracted from Appendix F - Nurse-to-nurse bullying: the RN way of RA]

Some examples [of relational aggression] include the following:

• Giving another nurse "the silent treatment" [Example here is from my own experience, not nurse-on-nurse; but I have seen it happening nurse-on-nurse.]
• Spreading rumours throughout the unit, hospital, or organization
• Humiliating or putting down another nurse, usually with regard to his or her nursing skills or abilities
• Failing to support another nurse because you don't like him or her (this could be anything from failure to help with care to disagreeing with decisions the nurse made) [Or working new staff like slaves, e.g. see the block quote in this blog post on "Pneumonia".]
• Failing to come to another nurse's assistance because you don't like him or her (a particular problem in EDs [Emergency Departments] and psychiatric units)
• Refusing to share information with another nurse or otherwise setting him or her up for failure [Click here or here.]
• Excluding another nurse from on- or off-the-job socializing
• Repeating information shared by one nurse out of context so it reflects badly on him or her
• Running a smear campaign or otherwise trying to get others to turn against another nurse
• Sharing a confidence you were asked to keep private, and perhaps twisting it a bit out of context
• Making fun of another nurse's appearance, demeanour, or other trait. [E.g. I have noticed this behaviour occasionally from a few Filipino GNIE classmates; I am not proud that I was a silent observer.]
• Manipulating or intimidating another nurse into doing something for you
• Using body language (such as eye rolling or head tossing) to convey an unfavourable opinion of someone. [This happens a lot in Singapore wards.]
• Saying something unfavourable, then pretending you were joking. [E.g. I have noticed this behaviour occasionally from a few Filipino GNIE classmates; I am not proud that I was sometimes the victim and more often a silent observer. If the victim reacts negatively and/or calls out their uncivil behaviour, they would gossip amongst the Filipino group that the victim was "too stressed, and needs a good fuck."]
• Name-calling
• Making a nurse look bad in front of patients, other nurses, or supervisors. [E.g. Read the comments in this blog entry or here.]
• Teasing another nurse for his or her lack of skill or knowledge

The Joint Commission for Accreditation of Healthcare Organization (JCAHO), which is responsible for regulating acute care organizations, takes this issue so seriously that as of January, 2009, they require policies to be in place that will help detect and address relationally aggressive behaviours.

[Unfortunately in a really bad environment, the nurse manager may well be the bully himself/herself. Extracted from page 134 "How Managers Bully" - Nurse-to-nurse bullying: the RN way of RA]

These (managers' bullying tactics) include behaviours such as the following (to name a few):

• Publicly discipling nurses who have made mistakes
• Threatening consequences if nurses don't do what the manager wants
• Playing favourites
• Setting up certain workers to fail by withholding information

[Dellasega, C. (2011). When nurses hurt nurses - Recognizing and Overcoming the Cycle of Bullying. Indianapolis, IN: Sigma Theta Tau International Honor Society of Nursing]

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I have seen a lot of ugly behaviours while nursing in Singapore -- the stuff that I wrote in my blog about workplace bullying is just the tip of the iceberg; i.e. stuff that won't get me or my previous employer (hospital) into legal trouble. I recognize that I have occasionally behaved as a bully too while surviving as a nurse in Singapore; and I am not proud of myself for that.

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What should one do when one finds oneself working amongst these sharks dressed as angels-in-white? Barbara A. Broome, PhD, RN, wrote an interesting article of practical advice - "Dealing with Sharks and Bullies in the Workplace". Here's an extract of her advice.

1. Assume all unidentified fish are sharks. ... In other words, you don't really know who or what you are dealing with, so be on guard.
2. Do not bleed. ... In the case of bullying, remove yourself from their presence. Giving way to crying, using defensive behaviour or trying to provide an explanation only provides more opportunities for aggression.
3. Those who cannot learn to control their bleeding should not attempt to swim with sharks for the peril is too great. When attacked, control your anger and state only the facts. Controlling your anger changes the power of the bully. The bully will be confused as to whether or not the attack has injured you and will be unsure of their advantage. ... Always document the interaction.
4. Counter any aggression promptly. Sharks and bullies rarely attack without warning. Usually there is some tentative, exploratory aggressive action. It is important that one recognizes that this behaviour is a prelude to an attack and take prompt and vigorous remedial action. The appropriate countermove is a direct discourse about the inappropriate behaviour.
5. Avoid ingratiating behaviour. One may mistakenly believe that an ingratiating attitude will dispel an attack. This is not correct; such a response provokes a shark attack.
6. Use anticipatory retaliation. One needs to develop the skill to counteract inappropriate behaviour. A constant issue is that the bully will forget and may attack in error. ... This memory loss can be prevented by a program of anticipatory retaliation. ... Your response to inappropriate behaviours is unexpected and serves to remind the bully that you are both alert and unafraid.
7. Identify disorganized and organized attack. There may be more than one bully acting in concert. ... It is essential that one know how to handle an organized attack. Confront the behaviour. Make it known that the behaviour is unacceptable and will not be tolerated. If the behaviour continues, a written complaint should be filed in human resources with the dates, times an details of each event. If there are witnesses to the event, their names should be included. A copy of all written communications should always be kept as a record of filing of the complaint and actions. As a last resort, legal action may be necessary. [IMHO, I am sorry to say that "legal action" is unlikely to work in Singapore, no thanks to its labour policies that supports discrimination and suppression of labour rights.]

[Broome, B.A. Dealing with Sharks and Bullies in the Workplace. ABNF Journal, Winter2008, Vol. 19 Issue 1, p28-30, 3p]

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Mean Girls: Four Ways to Respond - by Susan Fee