Prejudice against minorities
Lateral aggression may be directed toward nurses who look, sound, or act different from the majority of the staff. Researchers have found that nurses have been targets because of their accents or ethnicity, because they are a float or per diem nurse, or because they received a promotion or honor that coworkers think is undeserved.
Gender falls into this category as well. Male nurses said that while their gender helps them with patients and administrators, it puts them at a disadvantage among fellow nurses. A study of Minnesota OR nurses found that male doctors treat male nurses better than female nurses and that they have better camaraderie. “I think I have better relationships with physicians than many female nurses because they know me better. And I stick out. You’re not going to remember every interaction you have with a tiny twenty-three-year-old blonde girl named Laura, because there are a dozen of those on my unit. You’re going to remember interacting with the random scruffy-faced dude who successfully helped a mother breastfeed for the first time,” said an East Coast nurse who is the only murse in a building of hundreds. “This also means that my mistakes are held against me longer and harder. But overall, I think my opinions are trusted more, and I’m viewed as more authoritative, even when I’m not. For the record, I don’t think it’s fair. I’ve been given opportunities that much more deserving nurses have been passed over for.”
In nursing school, the same murse said that his conspicuousness led instructors to have higher expectations of him than his female classmates. “My successes were highlighted in front of everyone, as were my failures. It’s like when the instructors were looking for an example, they picked the person who stood out the most, because I’m a guy,” he said. Now, at work among his colleagues, other nurses are more likely to “think I have a stick up my ass when I question anything,” and socially, “I usually end up feeling like the little brother, big brother, or comic relief, not part of the actual clan.”
The workplace “can be challenging” socially for male nurses, a New York City murse admitted. “I’m not really involved in my colleagues’ social functions outside work. Baby showers, wine tastings, bachelorette parties . . . Sounds fun, and while I do consider many coworkers my friends, a lone married man in his early thirties with a bunch of young women at these events would just be awkward.” Even when nurses like him don’t rely on their coworkers for socializing, nursing is such a team-oriented profession that bonding outside of the hospital can easily affect the working relationships within it.
Cliques
It would be shortsighted to dismiss Juliette’s complaints about her coworkers’ social exclusivity as trivial or irrelevant. Much of any workplace bullying comes from cliques, which both galvanize and hide the perpetrators. In material about workplace bullying, the American Nurses Association specifically stated, “Misuse of power can also occur when a nurse who, acting as charge nurse, shows favoritism toward friends or those in a personal clique while treating others poorly by assigning them more difficult assignments or by not offering to help. This misuse of power is done without regard for the nurse and the patient, and it exposes the vulnerability of both.” It is this sort of treatment that distressed Juliette.
Nurses spend long hours together and are dependent on coworkers both professionally and personally. Many studies have found that nurses have higher job satisfaction when they have positive relationships with colleagues. Of course, benign work relationships can form that leave some nurses feeling devalued or left out. A Louisiana pediatric nurse explained, “Some places have set weekends, so when you work full-time you always work with the same crew. Sometimes if you get switched or request the opposite weekend, it’s like you’re not a part of the team because you never worked with them, so they don’t help you like they help the others.”
More trouble comes when a nurse’s standing devolves from not quite fitting in to being alienated. A Michigan ICU nurse was tormented by a nurse practitioner who tried to rally other coworkers to “take her down.” The nurses tried to sabotage the ICU nurse, refusing to answer her questions and to teach her the electronic health record system. The nurse left the hospital because of this treatment.
A 21-year-old Southern ER nurse described a clique of supervisors as “something straight out of Mean Girls. They make each other stronger, like female bullies in high school.” Without the pack, these nurses seem socially needy and insecure, but “when they’re together, they go around wreaking havoc. While you’re running around frantically trying to take care of five patients, they’re sitting at the desk reading People, and looking at you, laughing, ‘Looks like you’re having fun over there.’”
Mean girls. Humiliation. Sabotage. Why is there such a strong bullying culture in a profession known for its empathy and compassion, and a profession in which even bullying victims enthusiastically gush about how much they love their job?
Oppression causes in-fighting
In 1909, Dr. Leon Harris told The New York Times that nurses were “subjected to a despotic set of rules and regulations which in their stringency and utter lack of justice compare favorably with Siberian prison rules.” The head nurses, whom Harris called “tyrants,” regularly fired young, pretty nurses in favor of less attractive women, and “abuse their position of power. Like many of their sex, their inclination to be petty and mean and small in their dealings with other women comes out strong.”
Harris went on to inform the Times that “the abominable outrages practiced on our young women at these institutions in the name of ‘hospital discipline’ ” included hazing young nurses, disgracing them for trivial reasons, micromanaging their lives outside of the hospital, forcing them to work when they were sick, ordering them to do kitchen work or scrub floors if the head nurse didn’t like them, and stripping nurses of the two hours of “off time” they were supposed to have during their twelve-hour shifts (a break that will have disappeared a century later). Certainly, nursing has changed since then, but Harris’s description illuminates the roots from which nursing grew.
Many people insultingly believe, like Harris, that nurses catfight because it’s women’s nature to, and the vast majority of nurses are female. Australian researcher Elaine Duffy has observed that people dismiss bullying “with statements like, ‘This is typical of bitchy females working together,’ implying that such behaviors are typically female.” That rationale is far too simplistic, but is related to a more plausible explanation.
In 1970, Brazilian philosopher Paulo Freire theorized that when a dominant group forces its own values and norms upon a less influential group, the oppressed group develops low self-esteem and becomes angry and aggressive as it tries to internalize those standards. As group members are made to feel inferior, they begin to disdain their own culture. Because the oppressed group won’t engage in violence against the more powerful dominators, its members turn on each other, dividing and infighting, sabotaging each other. Freire called this conduct “oppressed group behavior.”
Some nurse scholars contend that nurses are an oppressed population because of a history of submissiveness to mostly male physicians and administrators. In the early 1900s, doctors controlled nursing school curricula, steering programs to instruct nurses primarily on how to support physicians. Without autonomy or control over their occupation and treated by medical professionals as subordinates, nurses took on the characteristics of an oppressed group. As the Center for American Nurses reported, “The culture of the healthcare setting has been historically populated by images of the nurse as a ‘handmaiden’ in a patriarchal environment. The balance of power has not been in the nurse’s favor. . . . Too often, nurses have acquiesced to a victim mentality that only facilitates a sense of powerlessness.”
Browbeaten by doctors, administrators, patients, and patients’ families, nurses also came to accept bullying as an inevitable part of the job. “Unfortunately, many nurses have been taught to simply ‘grin and bear it,�
� and as a result of prolonged abuse, nurses have become an oppressed group with nowhere to channel anger but at other nurses,” according to St. Joseph’s University researchers.
Venting to doctors or administrators could jeopardize nurses’ jobs, so they redirect their rage, frustration, or fear against each other, for which there are few repercussions. Interestingly, studies have found that when nurses are empowered at work, bullying occurs less frequently. This correlation supports the idea that when oppressed group members gain influence, they are less likely to lash out at each other.
Stress and burnout lead to bullying
When a healthcare organization does not empower employees—or when it restructures, downsizes, or keeps nurses short-staffed—nurse bullying increases. Studies have found that environments with volatile workloads, degenerating patient health, and increasingly confrontational patients and visitors create “a perfect storm for workplace bullying.”
This could tell us that when nurses are overly stressed and under excessive pressure, they become hostile toward the people they most frequently encounter during the workday: other nurses. Indeed, experts say that nurses who are burned out at work “are more likely to vent their frustration by abusing other nurses.” What other outlet do they have? In departments where nurses are rarely afforded the time to eat or go to the bathroom, they certainly wouldn’t be able to go for a walk or step outside to compose themselves. Stuck in their unit for hours on end, they can be so physically and emotionally worn out that they have little left for themselves, let alone each other. Nurses who are too drained or busy to take the time for self-care are more likely to engage in lateral aggression.
This theory could help to explain why bullying is so rampant among healthcare professionals. Not many workplaces are as tense and simultaneously as emotionally and spiritually draining as a hospital. It is evident how the cycle might perpetuate: Multiple studies have found that bullied nurses have much higher levels of burnout than their peers. If these victims, now burnt out, need an outlet themselves, they might be more likely to engage in the same bullying behavior.
Does hazing make nurses stronger?
There may be a reason why nurse bullying commonly targets young, inexperienced, or newly transitioned nurses. It’s arguable that there is a difference between the kinds of workplace bullying that are universal across professions and the type that qualifies as nurses “eating their young.”
Nurses told me that colleagues want a new nurse to prove herself before they accept her as part of the team. “There is a sort of test new nurses need to pass to become part of the nursing clique,” said a California nurse practitioner. Because of the nature of the job, nurses hold one another accountable to strict standards. “Due to the broad base of knowledge we must have, and many of us being ‘Type AAA’ perfectionist personalities, we have very high expectations of our peers,” a Missouri public health nurse said.
As a result, some nurses are short on patience and stingy about sharing knowledge, in order to toughen up new nurses. “Eating their young” refers to “the fact that a new nurse has to earn the right to work in the unit. No one gets any slack for being new,” said a Pennsylvania OR nurse. “You have to jump right in and be able to care for the most difficult patients as if you’ve been doing it a hundred years. Even when I moved to a new facility and had been doing the same job previously, there was this feeling of being tested to see if I would measure up and fit in.”
This philosophy leads some nurses to assign new nurses the most difficult or highest number of patients without assisting them, or to give them a hard time when they don’t know what to do. “Nurses put their own on steep learning curves to test their mettle. It’s sick and often counterproductive,” said a Virginia labor-and-delivery nurse. “Older or very insecure nurses often push the younger ones by giving them too many tasks to complete and not enough support.”
But making someone feel worse about her skills is not the same as making her a better nurse. And sometimes the “testing” goes too far. As I interviewed nurses for this book, many stories sounded similar to those of the college girls I interviewed for Pledged, a book investigating sororities. Like sorority sisters, nurses told me about overbearing cliques, governance by administrators more focused on money and image than on people and substance, arbitrary standards regarding their looks, and, most relevant to this section, a long tradition of hazing and questionable rites of passage.
Nurses eating their young is a form of hazing, different from other types of workplace bullying both within and outside of the nurse profession. It is as if nurses, like sorority members, have to endure a pledge period during which they must prove themselves worthy of a group that has already admitted them. A Texas nursing school professor referred to nurses eating their young as “sorority initiation.” Nurses in other states told me about rituals such as an OR’s tradition of initiating new nurses (most often the young, pretty ones) into the department by dunking them into the scrub sink with the water running.
Even American Nurses Association (ANA) literature called nurse bullying “a type of initiation to determine if the new nurse is tough enough to survive in nursing.” (The ANA added, “But the problem extends beyond the new nurse to include nurses at all levels as potential victims.”) A Florida psychiatric nurse told me, “Older nurses being harsh to newer nurses is almost like a ritual. I think sometimes it’s done subconsciously. We can be harsh to new nurses to make them strong for the many challenges they will face in this profession.”
When a North Carolina nurse started out in the ER, she said the old guard “punished” her for being young and attractive. If every other nurse had zero patients and she had four, her colleagues would assign her a fifth. “The existing nurses had been there for eons and felt they owned the place. They treated new staff however they pleased. I cried on the drive home every day for my first six months,” she said. “I was in the Marine Corps before this, I survived boot camp. [I thought] surely I could take all of the mean, snarky, underhanded hazing. But I wasn’t at that hospital longer than a year because of it.”
An Idaho murse said he was hazed a few years ago partly because he was a new graduate, but mostly because he is male. “I was treated like an idiot for the first several months. They made snide remarks or didn’t value my opinion. Also, as a man, I was expected to act differently in crisis. Starting as a new nurse was terrifying. When someone is actively dying in front of you or having a psychotic episode, it takes some getting used to, regardless of gender,” he said. “When I was giving report, it was as if I were being interrogated by the Gestapo. I’d be asked questions I didn’t know and treated like an idiot for not knowing the answers. I had to earn every ounce of respect that I got. ‘Eating their young’ comes from the need to weed out nurses who don’t belong, but there must be a better way to go about it. My experience was awful.”
Researchers have described how experienced nurses use lateral aggression to keep younger nurses and students in their place. By making the less experienced nurses doubt their ability, they create a perceived hierarchy tiered by seniority. This is not unlike sororities grinding pledges down to rebuild them in the preferred mold. “Here, a select group of senior nurses take any opportunity to tear a nurse down. Entering an ICU, I thought I’d have a great preceptor to teach me everything I’d ever need to know. But I really felt like I was set up for failure,” said a cardiovascular nurse who was hazed repeatedly. “New nurses are inevitably going to make mistakes, but senior nurses feed off it and make it worse. I understand that you need to know your stuff, but those nurses are there to teach you.”
When an inexperienced coworker was assigned to a case that was out of her depth and she was afraid she couldn’t properly serve the patient’s needs, she asked her preceptor and the charge nurse for help. “They left her to drown,” the cardiovascular nurse said. “She broke down in tears in the middle of morning doctor rounds. Unfortunately, I think thi
s will continue, because when new nurses bring this up as bullying or harassment, it gets pushed aside or sounds like tattling.”
Significant numbers of Greek alumni believe their college sorority is more cohesive because they suffered through hazing together; and that because they participated in the hazing tradition, so should every group that follows. Similarly, Boston Medical Center’s Martha Griffin has observed, “Tolerance for some forms of nursing practice lateral violence is seen historically in the context of a rite of passage or expressed in the thought ‘this is how people were to me, when I was learning.’”
Australian researchers report that nurse bullies “are usually themselves past or current victims and most are convinced that their experiences have strengthened them for their nursing role.” Under the guise of teaching younger nurses to be strong, these nurses appear not only to prefer to see new colleagues fail than succeed, but also to help them along in the process of failing. “Why do we tear each other down so much?” a Texas ER nurse wondered. “[They act like] they earned their stripes the hard way, the ‘old fashioned way,’ so they don’t want to make it any easier for the new nurse learning the ropes. It’s like the parent saying, ‘When I was your age, I got beaten with a log, so you should be thankful when I do it to you.’ Right, it was terrible the things you had to go through to get to where you are now. Shouldn’t you then want to make it easier for someone else, so they don’t have to experience that kind of heartache?”
The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital Page 17