The Mission of the Board
The Oregon Board of Nursing (OSBN) protects the public by regulating nursing education, licensure, and practice. Under this authority, incivility and bullying, inasmuch as they affect patient care, fall into the purview of the OSBN. Any action or inaction by nurses impacting the safety of the patient and the public is the business of the Board.
What exactly is “incivility and bullying”?
There are those who claim that their perceived “bullying” is simply asserting their opinion. “Assertive” behavior is defined as advocating for yourself in a respectful, but determined way, while acknowledging the feelings and rights of others. “Incivility” is rude or disruptive behavior that can result in physiological or psychological distress. “Bullying” is a more severe form of incivility and is defined as repeated, unwanted harmful actions over time that are intended to humiliate, offend, or cause distress to the recipient. Bullying involves the misuse of power, either formal or informal that can be top-down (supervisor-employee) or down-up (employee-to-supervisor), or horizontal (employee-to-employee, nurse-tonurse). Bullying is symptomatic of broken professional relationships within the work environment and its consequences extend far beyond the individuals involved.
When behavior becomes a concern for the Board
Studies reviewed for this article have shown that bullying and incivility have been shown to have a negative effect on the safety of patients and on the trust that patients have in nursing. The feedback from nurses regarding the effects of bullying speaks to the impact on the ability to provide safe care:
felt their ability to concentrate is impaired due to bullying
reduced communication regarding patient condition to peers or to other levels of care as a result of bullying behavior
believed that disruptive and bullying behavior are linked to medication errors
experienced that disruptive behavior and bullying led to patient mortality
The Board has jurisdictional authority when this type of behavior affects the practice of nursing and patient safety.
What does bullying look like?
The following are some examples of bullying behavior that can affect the practice of nursing and patient safety:
- Ridicule of others in front of other staff or patients.
- Keeping a constant eye on another’s work, even if the other staff have already shown competency.
- Questioning another’s professional ability involving all members of the healthcare team.
- Spreading damaging rumors to denigrate the reputation of another.
- Explosive outbursts and threats.
- “Petty tyranny” by managers toward staff.
- The bully implies negative consequences for the recipient.
- The recipient finds that the balance of power (either formal or informal power) is in favor of the bully, which makes it difficult for the recipient to defend themselves.
What if the behavior is left unresolved?
Poor morale, staff turnover, and concerned patients and families are the most common effects of a bullying environment. However, if left unresolved, two other, behaviors that are more serious can start to manifest themselves:
1. Moral Disengagement: Justifying unethical actions by altering one’s moral perceptions of those actions in an environment that enables individuals to engage in negative behavior from small misdeeds to atrocities without believing that they are causing harm or doing wrong. Example: Taking shortcuts regarding infection control because this is how it is done in your unit. When a certain bully is on shift with you, there is no way you are going to ask for help, even if you feel the care you are providing is no longer safe.
2. Organizational Moral Disengagement: An institution can result in which systems and processes are dysfunctional and/or cultural issues exist related to power differentials or disruptive behavior. The act of advancing organizational interest regardless of the ethics of the decisions. Example: Requiring staff to enter documentation for activities that did not occur to increase billing or to mitigate risk.
What causes this type of disengagement progress?
There are a number of reasons bullying progresses to disengagement, including:
- Informal power is bestowed by peers upon an individual or group of individuals resulting in others feeling they have no power. Informal power is usually bestowed upon a staff member whose personality is powerful enough that some give in rather than assert themselves.
- Formal power assigned by the organization when there are those who do not recognize the authority or feel the authority is not acting in their best interest. Examples:
- New nurse manager brought in to “clean up,” the informal power within the staff feels that there is really no reason to “clean up” and continue to recognize the unit culture rather than the authority of the manager.
- A peer who has become a manager and the informal power brokers do not recognize the peer in their new role (that has inherent authority bestowed by the employer).
- Unit or institutional culture being preserved when there is a change in the organizational direction. This is when statements such as, “They can do what they want, we are the X department/unit/floor/etc., and we will continue as usual,” and, “They don’t understand how things are out here,” are heard. When there is a lack of communication between all levels of the organization, this type of disengagement can affect all parts of the organization, not just nursing.
Why is unit or organizational culture so important, and how does a culture evolve?
This is an overall generalization of how a culture develops and is certainly not true in all cases. Nurses are educated as generalists, and then they go out and find employment. If you are fortunate, you will find a position in an area of choice, while others find a job where they can. Eventually a nurse adopts the identity of the specialty area more so than their identity as a “nurse.” “I am an ICU nurse,” or “I am an OR nurse,” etc. Some, especially those employed by not-for-profit, public, or religiously affiliated hospitals, start identifying themselves with the mission of the organization as well as their unit. Nurses who are hematology/ oncology nurses in a children’s hospital may have more ownership of their organization than others. They identify with that specialty
and no longer accept that all nurses are initially educated in the same interventions and tasks. Professional identity is enmeshed with the identity of the unit or organization. The shared behaviors, values, and assumptions become the norms and the expectation of the group…the unwritten rules. When those rules are unknown to a newcomer, a new manager, or challenged by organizational change, it sets the stage for bullying behavior to assure survival of the established culture.
Bullying is not a one-way street.
A study in 2010 cited workplace competitiveness, job insecurity, and resistance to organizational change as reasons for staff bullying their managers. Usually this behavior manifests as passive-aggressive behavior. Passive–aggressive behavior is defined as indirect resistance to the directives of another while avoiding a direct confrontation, usually manifested by agreeing but not doing, procrastination, or gestures and body language.
What does the Nurse Practice Act say about this type of behavior?
OAR 851-045-0040(5) (f): When a licensee has determined that an order or recommendation is not clear, unsafe, contraindicated for the client or is inconsistent with the overall plan for the client’s care, the licensee has the responsibility to decline implementation and contact the health care professional making the order or recommendation. If a provider states that an order will be implemented simply because they wrote an order, this can be an example of bullying behavior. The provider is using their perceived authority to compel someone else to act when that person knows that the activity/order is not in the best interest of the client. There is no authority over the practice of nursing except for the Nurse Practice Act and the Board. No other licensee of any healthcare licensing Board can compel a nurse to act against the best interest of the client. Bullying stops when both sides acknowledge the power and authority of the other and come to a mutual agreement as to the next course of action.
OAR 851-045-0060 (2) (k): Demonstrate honesty, integrity, and professionalism in the practice of nursing. Bullying is a violation of this part of the practice act.
OAR 851-045-0069 (2) (k): Ensure unsafe nursing practices are addressed immediately. As previously stated, bullying can lead to patient safety issues. When the bullying impacts your nursing practice, such as not asking for help when you need it because you fear the bully’s reaction, or you change your schedule based upon who is working or who is in charge, this is when bullying crosses over into the practice of nursing.
ORS 676.150 mandates that all licensees of this state report any other licensee who has displayed prohibited or unprofessional behavior to the offender’s licensing Board. The OSBN does receive several complaints per year about unprofessional nursing behavior from other members of the healthcare team under this law.
OAR 851-045-0070 (6) defines (a) engaging in violent, abusive, or threatening behavior toward a co-worker, or (b) engaging is violent, abusive, or threatening behavior that relates to the delivery of safe nursing services as conduct derogatory to the practice of nursing.
Professional obligation to stop bullying behaviors…yours and theirs.
Denying that bullying exists in the workplace poses a threat to patients and to each other. The failure of nursing to change its culture to one characterized by respectful and equitable inter- and intra-professional relationships poses a threat to patients and nursing.