“Structural bullying,” or unfair or punitive actions by supervisors, is a major problem in the field. A New Zealand study found that more than one-third of nurse respondents believed they were neglected, had learning opportunities blocked, and were given responsibilities for which they were not equipped. Nurses report that charge nurses, nurse managers, and other supervisors can penalize nurses they don’t like by giving them undesirable schedules or patient assignments, piling on the workload, or pressuring them not to use their vacation or sick days. A nurse told University of Massachusetts professor Shellie Simons, “During my first pregnancy, because the charge nurse did not like me, I was assigned the most infectious patients: HIV, tuberculosis, and hepatitis.”
Some administrators use vague standard descriptors like “core values” to arbitrarily punish nurses. In the Northeast, a nurse was sent home without pay for wearing her hood up during the walk from the parking garage to the hospital, because the dress code for nurses on hospital property (even when they are not on the clock) prohibited hoods, jeans, and flip-flops. “Our hospital uses the term ‘professional behavior and attire’ to discipline at will, and all it takes is one complaint,” said a nurse at that hospital. The hospital’s managers demanded that nurses cover tattoos and piercings, “even though they were hired with them. They requested a nurse to alter her hair color because it was dyed an unnatural shade of red.” The administrators did not enforce these dress code policies on physicians.
Misunderstanding among specialties
Prejudices and perceived tiers among nurse specialties and degrees contribute to the animosity. A Hospital Access Management article reported that “nurses create a kind of hierarchy within their own ranks in which trauma and cardiac critical care nurses, for example, consider themselves the ‘cream of the crop.’ ” Some nurses joke that RN stands for “Real Nurse,” which denigrates Licensed Practical Nurses. (LPNs have taken approximately one year’s worth of courses; RNs have at least a two-year degree, a three-year diploma, or a four-year bachelor’s degree.) Nurses told me about rivalries among specialties, between hospital and rehabilitation nurses, and between hospital nurses and nurses at doctors’ offices. A cardiovascular ICU nurse said that because her specialty is often considered the top in the field, when she floats to other units, they give her the worst assignments. A nurse practitioner said that she and her colleagues call ER nurses “trauma jockeys” because they enjoy “blood and gore” and “gossip about the people who come through and the gore they see.”
Several nurses said that other units mistakenly believe their specialty is easy. “They think we don’t work very hard and that we’re not as tough as med/surg or ER nurses,” a Maryland postpartum nurse said. In nursing school, one of her clinical instructors, a medical/surgical nurse, told the class that if she were in postpartum, “I would get so bored. I like working hard.”
A school nurse in Louisiana told me, “People think I put Band-Aids on all day, but it’s not that simple.” School nursing is far more complex than the stereotype implies. “I think the public generally believes that school nurses want to take it easy and just do some first aid,” said Carolyn Duff, president of the National Association of School Nurses, which estimates that there are approximately 70,000 school nurses in the United States. “What’s really true is that nurses who work in schools are highly skilled and highly educated generalists who are responsible for both the children and the adults in their building.”
In fact, school nurses may have a larger potential patient load than other nurses. School nursing requires the technical skills to treat chronic disease conditions, as well as the intellectual skills necessary for disaster planning, Duff said. “For students who may not see the school nurse often, planning occurs for them whether their parents know it or not. Take something as simple as immunization compliance: School nurses are accountable for making sure their populations are immunized according to state regulations. They know which students are not immunized and make sure when there are outbreaks, those students are excluded from school for their own protection. They have a constant awareness of each student’s particular needs.”
A South Carolina trauma nurse confessed that she looks down on floor nurses and nursing home nurses. “I will absolutely admit that I am biased. To me, everything less than critical care is somehow below nursing. I work at the highest level of my degree and scope of practice. Why should someone operating at the bottom also be called a nurse? It’s like that sad-but-true joke: ‘What do you call the person who graduates from medical school at the bottom of their class?’ ‘Doctor,’ ” she said. “Sometimes I almost wish that my RN came with a gold star next to it, because I crave some extra recognition for how hard I work. I am an RN, BSN, CEN, and almost a SANE [Registered Nurse, Bachelor’s of Science in Nursing, Certified Emergency Nurse, Sexual Assault Nurse Examiner]. Yet to the doctors and the patients I’m ‘just a nurse.’ ”
Part of the problem may be a lack of understanding among the specialties. For example, when I interviewed floor nurses across the country, I raised Molly’s complaint that floor nurses made excuses to avoid taking new patients at shift change. They told me that the reason they prefer not to take new patients then is because the chaotic timing could jeopardize patient safety. When ERs transfer a new patient at shift’s end, some floor nurses call it a “dump and run.” An Indiana psychiatric nurse said, “We don’t like taking patients at shift change because that’s the time when everything and everyone are the most disorganized, so the patient won’t get the attention he or she deserves. It’s not fair to the patient and it’s stressful for the staff.”
For approximately half an hour, the outgoing floor nurse is so busy giving report that she cannot give a new patient the necessary one-to-one time, which can involve a more complete medical assessment, settling in the patient and family, activating orders, writing admissions paperwork, starting labs, collecting specimens, documenting, setting up the room, making sure the patient is stable, etc. “We don’t just take vitals and tuck them in,” said an Arizona pediatric oncology nurse. The floor nurse needs to be with the new patients so she can pick up on a potentially life- threatening situation. As a Washington, DC, acute care nurse practitioner said, “It’s not safe to leave a patient who was just sitting in the ER alone in a room for that long while I’m speaking with someone else.”
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.”