What student nurses learn and what they experience, either positive or negative, during their formation as a nurse will forever become part of their character. Horizontal violence is common among students for many reasons and perpetuated because they see themselves as powerless. Unfortunately, much research on violence and bullying in nursing usually excludes student nurses in sample populations, and there have been few studies done on the correlation of horizontal violence and nurse bullying and the effect on student nurses. Not only are student nurses victims of bullying, but they themselves become bullies as well. This impact must be addressed as well, because student nurses are our future in the health care system, and the lives of patients depend on the student nurse becoming a just and moral citizen.
Student nurses compete for entrance to nursing school; this pits them against their peers. Then, once in nursing school, they are often met with an instructor who says, “Look on either side of you; that student won’t be with you when you graduate.” This introduces fear of failure and adds to an already stressful environment. The degradation of students continues throughout their clinical rotations and classroom attendance. After graduation, they then must compete for intern placement, academic honors, and job placement. This struggle does not create a colleague, but rather a competitor against whom the student must win or face failure.
Student nurses suffer from lack of sleep, lack of a social outlet, intense worry, stress, and anxiety. Unless they have developed healthy coping mechanisms, this stress is turned outward onto fellow students, faculty, and family, resulting in negative comments and behavior and angry outbursts. Students may also face bullying from several different sources, including staff nurses, clinical and classroom instructors, patients, instructors, visitors, and fellow students.
The most common type of bullying against student nurses is verbal assault, and clinical instructors have been identified as the main source of bullying behavior towards students.
Bullying behavior experienced by student nurses includes: being excluded or alienated; receiving destructive criticism; experiencing resentment; being humiliated in the presence of fellow students, staff, or patients; having their work undervalued; being treated with hostility; being blamed for patient care incidents that were the fault of the staff; being ignored by staff or the preceptor; lack of communication; being threatened with a poor evaluation that may be the result of changing clinical expectations that were not communicated; and faculty who “mentally sabotage” them by not being clear about testing or clinical expectations.
All of bullying forces converge against the student, not allowing him or her to reach full potential. Bullying has a direct effect on the confidence level of the student and causes personal and professional outcomes similar to those of bullied staff nurses. This includes feelings of decreased self-esteem, lack of autonomy, decreased self-worth, anger, fear, low morale, frustration, anxiety, increased errors, stress, apathy, burnout, guilt, worry, sleep disturbances, and symptoms similar to post traumatic stress disorder.
It is the professional and ethical responsibility of faculty within schools of nursing and individual nurse educators to educate their students, beginning early in the process, to recognize signs of bullying from all persons with whom they currently interact or will interact with in the future, including patients, staff, fellow students, instructors/professors, and preceptors and to suggest strategies for a solution.
Nurse educators can help change how bullying is addressed in the following ways:
- Educate students on what bullying and horizontal and lateral violence are as well as their impact on patient care.
- Prepare students prior to entering their clinical area for bullying behaviors they may encounter and how to manage their behavior.
- Teach students prior to their graduation about the behaviors they may encounter at a new job and how to manage those behaviors.
- Allow students to freely express themselves about negative interactions they have encountered and how they dealt with the behavior.
- Acknowledge that role playing and conflict resolution should not be considered the “cure” for the bully or the victim. These strategies may actually encourage further bullying behavior if the school of nursing does not utilize other strategies to recognize and end the behavior.
- Ensure that those who precept students are educated in how to effectively precept.
- Teach students whom they need to inform if bullying or violence occurs. The school and health care facility policies and procedures regarding bullying reporting must be reviewed with the student. This includes witnesses to bullying.
- Make sure that students, in turn, feel safe in reporting to their instructor, faculty, preceptor, and later on, to a unit manager. They must feel that their complaints are taken seriously and will be acted upon and are held in confidence.
- All educators, including preceptors, should be knowledgeable in the methods to resist bullying and horizontal violence as well as to identify it.
- Educators in every venue, classroom, or clinical area must model behavior that includes effective methods for reducing hostility.
- Enforce a zero tolerance policy for abuse, bullying, or violence. Nurse educators should model that nothing but respect will be tolerated from any health care professional, student, patient, or visitor.
- Teach students that violence, bullying, and verbal abuse are not a part of nursing, and enduring them is not a rite of passage!
- Encourage all nurses to model professional behavior. What is seen by students is imitated by them. If students experience bullying and the bullying is condoned, they will become bullies and the cycle will continue.
- Clinical instructors should be knowledgeable in not only clinical skills but also in how to effectively communicate and interact with students and staff.
- All nursing schools and universities have a responsibility to define bullying, and to design and implement anti-bullying policies and procedures.
- Provide students with information of outside or university support for victims of bullying.
- Make students aware of the psychological effects of bullying and also coping mechanisms to deal with stress.
The American Nurses Association urges health care to eliminate all forms of bullying and incivility from our workplaces. Nursing and health care leaders, including the ANA, often leap immediately to declare that facilities follow a “zero tolerance” policy when dealing with bullying thinking that it will eliminate the behavior. The literature, however, reveals that this implementation rarely succeeds when used in isolation. One reason is that those enforcing the zero tolerance policies are bully’s themselves. In other words…zero tolerance may have zero effectiveness.
When nurse leaders are silent in the face of bullying and uncivil behavior, they unknowingly (or knowingly) condone the behavior. If staff observes leadership tolerating bullying and uncivil behavior, then they feel they have no recourse and no one to turn to for help; staff does not feel that they can safely report being bullied. The bully sees this silence as acceptance and continues the behavior. Those that bully have a supportive atmosphere to continue terrorizing their colleagues. They are supported as they move ahead in their career and to various job postings within the facility, thus reinforcing the fact that a bully is very often in a leadership position. This is compounded if the bully-leader is also productive and meets the goals of the facility. Very often leaders may not approve of the behavior or even be aware that it is occurring, but the staff understands that silence is acceptance.
It is a well-known fact among staff nurses that many of those in nursing leadership do not belong in their positions and that many in hospital or facility administration don’t belong there ether. Whether it is a lack of education in organizational leadership or a lack of experience, many nurse managers and administrators have difficulty dealing with day-to-day issues let alone bullying on a unit or within the facility. It is also well-known that managers often ignore policies on bullying because they feel that they are ineffective or that bullying itself is not an issue.
Many nurse managers unfortunately see their staff only as employees there to get a job done. Staff presence or absence affects patient care and the bottom line. The victim is not seen as a person with rights.
Nurse leaders should:
- Receive evidence-based education regarding bullying, incivility, and workplace violence.
- Be aware of their own actions and words…are they a bully?
- Name the action of a perpetrator as “bullying” or “horizontal violence” – get it out in the open and freely expressed.
- Take the opportunity of staff meetings to speak on the issue. Use this as a teaching moment and to express that bullying will not be tolerated.
- Ensure that there exists facility policies in place to deal with bullying, and if not, be a part of team that creates them.
- Be fully committed to eradicating bullying from a unit/facility.
- Avoid moving a bully from unit to unit in order to avoid removing a productive employee. This sends a signal that bullying is condoned.
- Create and enforce a culture of respect.
- Immediately acknowledge staff concerns and complaints, but act on sincere, accurate information.
- Actively listen to concerns of staff.
- Be on the lookout for the formation and existence of cliques.
- Ensure that self-governed staff decisions are fair, accountable and responsible.
- Be supportive of all staff.
- Ensure that those staff that precept students or new staff are educated as to how to do so.
- Be fair and consistent in dealing with all staff.
- Be aware, at all times, of unit culture – has anything altered the emotional atmosphere of the unit? Be aware of morale.
- Be sympathetic and empathetic.
- Be a champion of open communication.
- Be supportive of those continuing their education.
- Don’t blame the target of a bully.
- Ensure that staff are accountable for their actions.
- Encourage assertiveness, discourage aggression.
- Ensure adequate, safe staffing levels.
- Make bullying victims aware of employee assistance programs.
Orientation or preceptorship is the introduction to your new career and job and may be long or short in duration. Depending on the area in which you are working, it may encompass several days of classroom learning followed by unit orientation. If you are expected to float, you may also be expected to orient on several different units. No matter the length of orientation, there are several things you can do to make your orientation as smooth an experience as possible.
- Know prior to your first day what type of uniform to wear or the organization’s dress code, what time to show up, where to show up, and what supplies to bring.
- Many areas of nursing, particularly subacute and rehabilitation, may expect you to bring your own thermometers, blood pressure cuffs, and pulse oximeters. Question whether this is the case in your work area.
- Have access to unit specific (i.e. medical surgical) information, skills instructions, and patient drug information in case your facility does not have skills, policies, procedures, and other resources online.
- Complete all necessary paperwork and/or online educational offerings as required.
- Review a unit specific text. This will help to refresh your member on basic concepts.
- Review your nursing skills text.
- If your facility uses electronic medical records, you must still be aware of how to properly author a narrative note and what information is important to include in your documentation. Review documentation guidelines.
- Consider adding an application to your cell phone to access key references. Be aware, however, that some institutions will not allow you to access your phone during work time
Meet and Greet
- Arrange to meet your preceptor (and some of your fellow staff) prior to the start of your orientation or work experience. When you return for your first day of work, seeing a familiar face will help to reduce your stress level.
- Take the time prior to your first day to meet with the staffing coordinator. Obtain a copy of your schedule. Negotiate for any days off you are aware of needing for preplanned vacations, school, or other circumstances.
- Seek out new learning opportunities. It can be a way to introduce yourself to other members of the team.
- Practice good communication. Be an active listener.
- Inquire whether you will be orienting on the same unit and on the same shift. New nurses are often moved from unit to unit during orientation to learn in multiple areas and from multiple nurses.
- If you are moving throughout the facility during orientation, be sure that you will be with one nurse during that time on a specific unit. If you are inconsistently supervised by your preceptor, the documented or actual outcome may not be ideal or fair.
- If your preceptor takes time off during the preceptorship, your orientation may not go smoothly. If his or her time off is excessive (say a week or more), inquire whether you may be assigned another preceptor.
- If you are off an excessive number of days, you will not have a complete orientation and may be ill prepared to work. Plan your vacation accordingly and give yourself plenty of time and opportunity to complete orientation.
- Be honest about your limitations, your skills ability, and your knowledge base. Think about enrolling in an RN refresher course prior to your job search. Make your preceptor aware of any limitations in skill level so that they can be addressed during orientation.
- Don’t perform nursing care outside your scope of practice. Know your limitations with regard to what you have been taught and basic nursing practice.
The preceptorship of a nurse or student has far-reaching effects, influencing everything from the safety of the patient, to the quality of care the patient receives, and the employment, retention, and job satisfaction of the new nurse. The preceptorship experience will be remembered long after the preceptee has left the facility. How the preceptor conducts both himself or herself and the orientation period will not only influence how the preceptee feels about the profession of nursing for years to come, but the quality of care his or her future patients receive.
Listed below are behaviors attributable to an ineffectual nursing preceptor. If you notice that they reflect your teaching style, then take advantage of preceptor education. Recognize that these behaviors can be changed and that the most successful preceptors do not exhibit these qualities. You are an ineffectual preceptor if:
- You are unclear about the goals of orientation.
- You do not ascertain the preceptee’s skill and knowledge level prior to the start of orientation.
- You do not question the preceptee to determine if there are any patient care areas in which he or she feels weak.
- You do not introduce the preceptee to fellow team members and do not help the preceptee feel like part of the team.
- You do not orient the preceptee to the unit so that he or she does not know where items or located or typical procedures to follow.
- The goals and expectations for orientation are unclear and are not stated in writing.
- The goals you establish are not measurable or achievable.
- You do not review the goals for the day or for orientation with the preceptee.
- You are inconsistent in your communication style.
- You do not allow the preceptee time to practice skills prior to attempting them.
- You do not build new skills upon current skill level.
- You delegate to the preceptee beyond his or her skill level.
- You do not seek out new learning experiences for the preceptee but instead allow the preceptee to find learning situations on his or her own.
- You fail to provide guidance in the completion of a new skill, assessment, or other nursing function.
- Your clinical skills and technique are not evidence-based or correct; you take shortcuts to save your time but in doing so may unknowingly endanger the patient. You pressure the preceptee to perform these skills as you do.
- You leave the preceptee to do the work that other staff do not wish to complete.
- You are continually rude to the preceptee, fellow staff, families and patients.
- You allow the preceptee to experience a lot of “down time,” for example by allowing him or her to “hang around” the nurses’ station rather than engaging in patient care or learning new skills.
- You frequently cancel scheduled meeting times with the preceptee, the unit manager, the unit educator, or faculty members, therefore fallowing communication to break down among all parties.
- You allow the preceptee to be utilized as staff prior to the end of preceptorship.