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  1. Choudhary, Lena JD, MSN, RN

Article Content

BULLYING, INCIVILITY, and lateral violence are rampant in nursing. Some examples of bullying behaviors include gossiping, name calling, withholding information, eye rolling, favoritism, and social isolation (see Coming to terms with bullying).1


Experts in lateral or horizontal violence have identified bullying as a norm in nursing that has passed from one generation to the next. Additionally, working with limited resources and higher numbers of acutely ill patients can create a toxic work environment.2


Regardless of the underlying causes, incivility has found its way into academic settings as well. This article discusses different educational strategies to teach nursing students to identify bullying behaviors, develop techniques to deal with incivility, and encourage the pursuit of leadership roles to change nursing culture.


The "hidden curriculum"

Competition to get into nursing school and succeed has created a tense and aggressive educational environment. Students may experience incivility from their first day in nursing school.3 The author of one 2017 study found that half of the surveyed nursing students had experienced harassment and incivility during their education.4 Another author described it as the "hidden curriculum."3 If faculty members witness lateral violence in the clinical setting without objection, they are tacitly endorsing this behavior in the classroom.3


Often, nurses deal with conflict via one of two extreme approaches: avoiding and ignoring it or going on the offensive.5 Neither of these responses encourages collaboration that will lead to positive outcomes. Having studied the topic and presented on it at numerous conferences, a colleague and I set out to help students build the conflict management skills they need to deal with incivility and bullying without shying away from difficult conversations.


Unfortunately, what little time is spent on leadership course material barely allows instructors to touch on bullying and incivility. In our curriculum, we found limited room for didactic content. Because the critical skills required to address incivility are complex and require practice, we decided that simulation was our best option as a teaching technique. Simulation can take many forms, ranging from tabletop role-playing to high-fidelity simulations in a lab.


We wrote, directed, and produced an instructional video to be used alongside the National League of Nursing (NLN) simulation design template to help nursing educators teach tools for conflict management, discuss relevant issues, and practice difficult conversations.6,7 The standardized NLN template allows any nursing educator to understand and implement a simulation and provides assignments on bullying behaviors and causes of incivility.7


Using the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) framework, the NLN template provides a describe, express, suggest, and consequence (DESC) script for practice in confronting and addressing bullying behaviors.7,8 The tool is intended as a guide for nurses as they address bullies directly. Following an upsetting event, a nurse can address a hostile colleague using the following steps:


* describe the situation that caused distress


* express how the nurse felt during the situation using "I" statements


* suggest a more professional manner in which to communicate in the future


* explain the positive after-effects of implementing the suggested practice.



The NLN template provides suggested standard debriefing questions, such as "Discuss the knowledge guiding your thinking surrounding these main problems." Additionally, a guide of alternate questions and discussion points is available to apply the simulation materials in other formats, such as a seminar discussion.6,7


The video provides an example of nurse-on-nurse bullying, and the TeamSTEPPS framework, the NLN template, and DESC scripts are tools to help nurses express their concerns in an effective and professional manner.6,7 After applying the video and the NLN template in the simulation lab, however, we determined that just one simulation and one discussion would not be enough to change a culture that has existed for so long. My colleague and I are now advocating for incivility and conflict resolution as a standard part of educational nursing programs, similar to legal issues or caring behaviors. By incorporating conflict management and the relevant tools to address bullying, nurses can address communication issues in a far-reaching way.


Key questions

Almost every curriculum has end-of-program competencies related to communication. When reviewing a curriculum, we recommend that educators ask themselves these questions:


* Do you discuss what nursing students should do when a physician or other healthcare provider is dismissive or angry that the student called the provider?


* Do you discuss with your students how to handle particularly demanding patients?


* Do you discuss how new graduates should interact with experienced nurses?



Conflict management techniques are a critical component of effective communication and can go a long way toward improving team morale and fostering patient safety.9-14 These skills are improved with practice and lead to positive interactions.


The conflict management literature supports the necessity of practicing these difficult conversations (see Conversational Dos and Don'ts). Learning to say the right thing at the right time takes cognitive rehearsal, coaching, reflection, and repetition.15 The more often we practice with these tools, the easier it will be to conduct a civil discourse naturally.


Coming to terms with bullying16-18

Various terms associated with workplace incivility have been used, often interchangeably. Using the following terms precisely helps nurses identify, acknowledge, and address bullying behaviors.


* Bullying: covert or overt acts, actions, and behaviors that are intentionally abusive, demeaning, intimidating, and repeated over a period of at least 6 months, which interfere with other staff members' ability to complete their work


* Incivility: rude, impolite, and/or discourteous behaviors or acts


* Lateral violence: confrontational behaviors that are repeated over time by a peer at the same work level; also called horizontal violence.



Conversational Dos and Don'ts


* Don't address incivility immediately following the incident. Be calm and rational before starting this difficult discussion.


* Do practice the conversation and rehearse with a friend or family member (not another colleague). Practicing allows you to choose your words carefully and have a script in mind before entering the conversation.


* Don't blame the aggressor. Instead of stating: "You made me mad," or "You acted terrible," use "I" statements, such as: "I felt hurt" or "I felt embarrassed."


* Do act and speak respectfully. Your intention is to maintain the relationship but change the behavior.


* Don't have the conversation in public. A private conversation is preferred, as it allows the aggressor to avoid embarrassment.



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2. Szutenbach MP. Bullying in nursing: roots, rationales, and remedies. J Christ Nurs. 2013;30(1):16-23; quiz 24-25. [Context Link]


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4. Budden L, Birks M, Cant R, Bagley T, Park T. Australian nursing students' experience of bullying and/or harassment during clinical placement. Collegian. 2017;24(2):125-133. [Context Link]


5. Clark CM. Seeking civility. Am Nurse Today. 2014;9(7):18-46. [Context Link]


6. Simulation Resource: Managing Incivility. Montgomery College. 2018. http://cms.montgomerycollege.edu/edu/department.aspx?id=8522#managingincivility. [Context Link]


7. National League for Nursing. Simulation design template. National League for Nursing. 2018. https://sirc.nln.org/mod/page/view.php?id=843. [Context Link]


8. Pocket Guide: TeamSTEPPS. Agency for Healthcare Research and Quality. 2013. http://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html#descscript. [Context Link]


9. Omisore BO, Abiodun AR. Organizational conflicts: causes, effects, and remedies. Int J Acad Res Econ Manag Sci. 2014;3(6):2226-3624. [Context Link]


10. Rahim MA. Managing Conflict in Organizations. New Brunswick, NJ: Transaction Publishers; 2011.


11. Turkalj Z, Fosic I, Dujak D. Conflict management in organization. Interdiscip Manage Res. 2008;4:505-515.


12. Brinkert R. A literature review of conflict communication causes, costs, benefits and interventions in nursing. J Nurs Manag. 2010;18(2):145-156.


13. Johansen ML. Keeping the peace: conflict management strategies for nurse managers. Nurs Manag. 2012;43(2):50-54.


14. McKibben L. Conflict management: importance and implications. Br J Nurs. 2017;26(2):100-103. [Context Link]


15. Griffin M, Clark CM. Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. J Contin Educ Nurs. 2014;45(12):535-542; quiz 543-544. [Context Link]


16. Workplace Bullying Institute. The WBI definition of workplace bullying. 2018. http://www.workplacebullying.org/individuals/problem/definition. [Context Link]


17. Lachman VD. Ethical issues in the disruptive behaviors of incivility, bullying, and horizontal/lateral violence. Medsurg Nurs. 2014;23(1):56-58, 60.


18. Van De Griend KM, Hilfinger Messias DK. Expanding the conceptualization of workplace violence: implications for research, policy, and practice. Sex Roles. 2014;71(1-2):33-42. [Context Link]



Trepanier SG, Fernet C, Austin S, Boudrias V. Work environment antecedents of bullying: a review and integrative model applied to registered nurses. Int J Nurs Stud. 2016;55:85-97.


Weinand MR. Horizontal violence in nursing: history, impact, and solution. JOCEPS: The Journal of Chi Eta Phi Sorority. 2010;54(1):23-26.