Nurse Bullying is Real

From the Radical Nurses Group/Royal College of Nursing Archive, Edinburgh

In my almost 40 years of nursing, I have heard about, read about, and taught about nurse bullying, but I had never experienced it directly—until yesterday while working as a Covid vaccinator in a hospital setting.

The American Nurses Association (ANA) defines nurse bullying as “repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient.” As I write that, I wonder why they include “unwanted” in the definition. Who in their right mind would want to be bullied? And even if that were the case, it would not make bullying okay. The ANA includes bullying in its statement on workplace violence. They point out that nurse bullying threatens patient safety, diminishes quality of care, and contributes to nurse burnout/staff turnover. Nurses who are bullied suffer a host of physical and emotional repercussions, including higher rates of depression and suicide.

“Nurses eating their young” is an oft-repeated phrase when referring to nurse bullying. I imagine that Florence Nightingale was quite the nurse bully. It seems to be ingrained in our profession and treated almost like a necessary rite of passage. Nurse bullying can begin in nursing school, with students being subjected to humiliation and intimidation by professors, clinical instructors, and school administrators. In some studies (see references below), over half of graduating nursing students report having witnessed (bystander) or been the recipient of nurse-on-nurse bullying in clinical rotations. The vast majority of nurse bullying happens in hospital settings, perhaps perpetuated by the high stress, high stakes clinical outcomes, heavy workloads, and low job autonomy of nursing within the rigidly hierarchical hospital setting.

I know that many frontline hospital nurses across our country and in other countries hard hit by the pandemic are burned out and angry after over a year of treating patients with COVID-19 and seeing so many of them die. Many nurses are tired of being portrayed as “angels on earth.” And, of course, the pandemic is far from over despite the rollout of safe and effective vaccines. Perhaps the vaccine clinic nurse manager yesterday is one of those burned out, pissed off nurses. It doesn’t excuse the bullying behavior she threw my way (I’ll spare you the details but it went way past incivility) and to a patient who, post-vaccination, asked to use the restroom (located next to the clinic) and she told him curtly that he had to wait the full 15 minutes of post-vaccine observation. Seriously, a patient is a person who has the right to use the restroom. I’d had enough and escorted the patient to the bathroom, waited outside to make sure he was okay, and then excused myself from the presence of that nurse bully. And reported her behavior in the hopes that she will be removed from that specific role and offered professional coaching of some sort. But I’m not going back to that setting, at least not as a clinician. I’ll find a better place to volunteer as a nurse vaccinator.

I’m attempting to turn this distressing experience into a teachable moment, for myself, and for students I teach. I now know from direct experience that nurse bullying is real.

References:

Theresa Brown, “When the Nurse is a Bully,” NYT Well blog, February 11, 2010.

Cole Edmonson and Caroline Zelonka, “Our Own Worst Enemies: The Nurse Bullying Epidemic,” NURS ADMIN Q. 2019, vol 43(3):274-279.

Note: I received this message in response to this post:

“As I’m sure you know, workplace violence is a critical issue affecting not
only nurses, but patients and their quality of care. That’s why ANA
launched #EndNurseAbuse – a nationwide initiative to eliminate physical and
verbal abuse, sexual harassment, and bullying in the workplace.
#EndNurseAbuse galvanizes nurses, health care stakeholders, and consumers
across the nation to reduce violence and harassment against nurses. Visit the
#EndNurseAbuse resource center to see the video that brings to life actual
accounts from real nurses who have experienced various forms of violence and
abuse on the job. While you’re there, please take a minute to sign the #ENA
pledge and share!

Here’s the link to ANA’s official statement:
https://www.nursingworld.org/news/news-releases/2021/ana-applauds-passage-of-workplace-violence-prevention-legislation/

ANA Applauds Passage of Workplace Violence Prevention Legislation by U.S. House of RepresentativesMEDIA CONTACTS: Keziah Proctor. 301-628-5197 keziah.proctor@ana.org . Silver Spring, MD – Today, the American Nurses Association (ANA) applauds the U.S. House of Representatives for passing the Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R. 1195).This legislation, approved by a vote of 254-166, will help to better protect all health care professionals and …www.nursingworld.org

Deafening Silence: Teaching in a Time of Hate

I teach at a major public university that has yet to issue any statement about or even an acknowledgement of the appalling white supremacist mob attack on the United States Capitol two days ago, a mob directly incited by our current president. I teach at a university whose administration has allowed white supremacist hate groups on campus to openly recruit and brainwash students and distribute racist materials. (see my blog post, “Teaching in a Time of Hate and Violence.”) I teach at a school of nursing that has yet to issue any statement about this week’s life and history-altering events. Why the deafening silence?

Schools, colleges, and universities have a responsibility to respond promptly to crises such as the one we all find ourselves in. Students, faculty, and staff need to hear from leaders. I found myself in the position yesterday, in our first day of a winter quarter course on health equity (including racism) talking with students about Wednesday’s events, reviewing mental health resources, and letting them know that if something like that unfolds during any of our class sessions to feel free to bow out of class to take care of themselves and their loved ones. I also reminded us that health, individual and population-level, is only possible in times of peace and a functioning civil society. Teaching and learning are only possible in times of peace and a functioning civil society, with clear and competent leadership.

Note: After writing this post, I was alerted (indirectly) by someone in President Cauce’s office that she made this statement/blog post on her UW webpage on Wednesday, but no UW internal e-mail message was sent to students/faculty/staff. None of the students or colleagues I work with knew about/had seen her message. Which does beg the question of crisis communication…

Racism and Nursing

Bandaging a patient’s hand, Cross-Over Clinic, 1986. Richmond Times-Dispatch

Ibram Kendi writes, “We are surrounded by racial inequity, as visible as the law, as hidden as our private thoughts. The question for each of us is: What side of history will we stand on?” (How to Be an Antiracist, p. 22).

In preparing to teach population health nursing and health policy and politics again this coming academic year, I am working with the good folks at StoryCenter to develop media literacy content utilizing digital storytelling videos. And, since our University of Washington Health Sciences Common book will be Kendi’s How to Be and Antiracist (not to mention the current moment in terms of racism in our country), I plan to use digital storytelling focusing on racism and bias in nursing and health care.

Nurstory, working with StoryCenter, has some excellent digital storytelling videos by nurses across the country, including nurses with the Nurse Family Partnership. Dr. Raeanne Leblanc and her colleagues at University of Massachusetts, Amherst, completed a Nurstory project on social justice. My plan is to work with our students on the use and making of digital stories related to racism and bias. Since I believe that I should practice what I preach (or teach in this case), I recently made a digital storytelling video on my experience of racism in various aspects of nursing, including nurse education. Titled “Relics,” here it is:

Relics, Josephine Ensign, August 2020

Teaching Health Politics and Policy in the Time of a Pandemic

Where to begin? For one thing, I will begin by acknowledging that I still have a job, and I have a job that can be done from the “shelter in place” comfort of my own home here in Seattle. These are privileges that I am acutely aware that many others in my neighborhood, city, country, state, and world do not have. These are privileges that homeless people I work with do not have.

I will not complain about having to “pivot” (but oh how I loathe that over-used term right now!) and convert a new health politics/policy course from an in-person class format to completely online within a week’s time. I will not complain that the hastily-added Zoom feature on our course websites is already crashing and our spring quarter has not yet begun.

The course I designed and will be teaching starting next week is a required course for all pre-licensure nursing students in our newly revised curriculum that rolled out this past fall. I have a cohort of about 150 students, a mixture of traditional BSN students and accelerated BSN (ABSN) students–meaning they already have a degree and complete their nursing courses in one academic year. The ABSN students will soon graduate and enter the nursing workforce. Many of them, as well as the BSN students, are already working as nurse techs in hospitals and nursing homes. Since most of them live and work in the Seattle area—the site of our country’s first COVID-19 outbreak and known community spread and mounting death toll along with the insane shortage of basic protective gear like masks—they know first-hand two lessons included in my course syllabus: 1) US healthcare is characterized by excess and deprivation (rich people still getting tummy tucks and facelifts while COVID-19 patients die from lack hospital beds/staff/ventilators), and 2) rationing of healthcare is already a reality even before the COVID-19 pandemic reached the US.

Luckily, I had this same cohort of students last fall quarter in a community/population health course which we now lead with instead of including as an afterthought as most nursing schools still do. As part of that course, I had them complete the excellent (and free!) online training modules on disaster preparedness (include mental health/PTSD in first responders) from the Northwest Center for Public Health Practice. I also had them write a narrative policy paper based on Health Affair‘s “Narrative Matters” series of essays. Many of their papers were excellent and based on current event public health/health policy topics.

For the spring quarter health politics and policy course I will have them work in teams (virtually, of course) of ten students and write and produce 8-10 minute personal policy and advocacy storytelling videos based on current event topics (including the pandemic). These are based loosely on the StoryCenter/Nurstory series of videos, although all of theirs are single person-single story videos. (One of my favorites is “Pride and Prejudice” by Maud Low on reproductive rights.) I am excited to see what they come up with and will–with their permission–share/link to some of their final participatory/narrative policy videos at the end of the quarter.

In yet another surreal moment in the midst of numerous such moments during this time, I am struck with the fact that by writing/thinking about “the end of the quarter” I have the simultaneous realization that—assuming my students and I are still standing (or sitting, or lying) by then—we will all have been even more profoundly and personally touched by this pandemic.

The Future of Nursing

Lillian Wald’s public health nurse uniform

The future of nursing should begin with people and community/population health. And to do that we need to disrupt our tired, outdated approach to nurse education. Not by tweaking here and there. Not by investing tons of money in yet more high tech simulation labs and “dummies.” Not by asking ourselves and our students, “What would Florence do?” (as in the Florence Nightingale, important as she is). Rather, we should begin by asking, “What would Dorothea do?” (as in Dorothea Dix, US and international mental health reformer) and “What would Lillian do? (as in Lillian Wald, the “mother of public health nursing” and founder of the Henry Street Settlement House in New York City).

“Begin with people, not body parts,” is what one of our nursing students told us recently when she heard that we are disrupting our pre-licensure nursing program at the University of Washington. Starting this coming academic year (begins in September), we will begin with people—with community, public health nursing instead of the longstanding “traditional” acute care medical-surgical nursing. I am excited to be teaching this “new” community/public health nursing course. It will begin at the true beginning with the social determinants of health equity. Not just with the social determinants of health (SDH)—those factors that affect our health from where we live, work and play. The social determinants of health equity extends past the SDH to acknowledge and address the inequities inherent in our society that affect health, including structural racism, and all the other “isms” of longstanding discrimination against women, persons of color, LGBTQ people, disabled folks, and the aged. Dr. Camara Jones and her “Cliff of Good Health” is the best illustration of this.

The Future of Medicine 2030 Seattle Town Hall was held at the University of Washington this morning. This builds on and extends the work of the Institute of Medicine’s Future of Nursing report back in 2010. The theme of today’s town hall meeting was “High Tech, High Touch.” I was dismayed (okay, I was irritated) that the lead speaker at today’s event was a physician, Molly Coye, who is an executive-in residence with AVIA, a network of US health systems “solving problems with digital technologies.” It is the “The Future of Nursing” after all and not “The Future of Our Insanely Expensive and Ineffective US Healthcare System.” And it should be led by nurses!

The one truly inspirational speaker at today’s event was a nurse—Dean Kenya Beard from Nassau Community College in New York. She spoke of some of the drawbacks of health technology and how they can amplify health inequities and how most of the proprietary algorithms for high tech “solutions” lack transparency. She called out the pressing need for nurse educators to “rise above any level of discomfort” and address structural racism and interventions that work. As to structural racism in our country she stated, “humans created it and only humans can destroy it.” She ended her talk with, “We need daring ingenuity.”

My question/comment which I posted online during the town hall was this:

“Why aren’t we using the much more useful term “social determinants of health equity” versus the rather status quo term “social determinants of health”? Why aren’t we killing forever the outdated and unhelpful message to our nursing students that they “have to have at least two years of inpatient med-surg” work before they go on (yes, go on) to community, public/population health nursing? Why aren’t we stopping the practice of educating nursing students to be “agents of social control” and instead to be “agents of social change?” Also, thanks for the refreshingly honest and necessary presentation and perspective from Kenya—Brava!

In Praise of Curiosity

Photograph from inside the reconstructed room/installation piece  "Room No 2 1984" by Irina Nakhova. Tate Modern Museum, London
Inside “Room No 2 1984” by Irina Nakhova. Tate Modern Museum, London

It struck me this week that curiosity—the time and space necessary for nurturing curiosity—has little to no place in our institutions. Not in the university or in our classrooms or in the hallowed halls of government or in our health care system. Instead of open-minded curiosity that can lead to innovative solutions to big problems like homelessness, we rely on snap judgements and decisions based on our close-minded, biased, preconceived notions.

Curiosity did not kill the cat. Curiosity is necessary for growth and survival and resilience in the face of adversity. Curiosity is necessary for empathy, for perspective-taking and imagination and creativity. Babies and small children are naturally curious, but as they grow up, formal education largely forces them to suppress curiosity. Students, and especially university students, are typically afraid to ask questions for the fear of appearing incompetent and stupid. We grade students based on their answers and not on the quality of their questions. University professors, including nurse educators, do not model a healthy valuing and practicing of curiosity. We are forced to specialize in a “focused area of study,” to become (or at least to pretend to be) experts with answers and not wise educators with yet more questions. 

Tenelle Porter, Phd, a behavioral psychology scholar at the University of California, Davis describes intellectual humility as the ability to acknowledge (to ourselves and to others) that what we know is quite limited. She points out that university professors are not known for having high levels of intellectual humility, yet fostering intellectual humility (closely linked with higher levels of curiosity) in students leads to greater learning and later career success. In addition, intellectual humility is associated with a greater openness to hearing and considering different viewpoints—something that is sorely lacking in our society and in our classrooms. 

“Who Owns What?” by Barbara Kruger, 2012, Tate Modern Museum, London

Sources: 

Francesca Gino (2018) The Business Case for Curiosity, Harvard Business Review

Tenelle Porter & Karina Schumann (2018) Intellectual humility and openness to the opposing view, Self and Identity, 17:2, 139-162, DOI: 10.1080/15298868.2017.1361861

Tenelle Porter (2018) The Benefits of Admitting When You Don’t Know, Behavioral Scientist