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Urgent message: More than one third of U.S. employees say they have been bullied in the workplace. Does your practice have a policy in place to thwart this insidious problem? If not, it should.

Alan A. Ayers, MBA, MACC

What is the Difference Between Diversity and Tolerance?

According to one definition, diversity is anything that makes you different while tolerance is not persecuting people who are different. Many urgent care operations strive for a unified team focused on building the practice and delivering an outstanding patient experience. An array of experiences, perspectives, and talents should thus strengthen their organizations. Yet it many workplaces, honest, respectful communication gives way to politics, game playing, and power grabs, with the resulting behavior being “workplace bullying.”

If you think that workplace bullying isn’t relevant to your urgent care operation, consider these facts:

  • 37% of the U.S. workforce – 54 million Americans – report repeated abusive behavior at work.
  • 41% of Americans say they have been psychologically harassed at work.
  • 70% to 80% of Americans report recurring rudeness and incivility at work.
  • 82% of individuals targeted for workplace harassment leave their jobs.
  • Workplace bullying is four times more prevalent than illegal discriminatory harassment.

Odds are workplace bullying has either occurred or has the potential to occur in your operation and the results can be devastating to employees, patients, and the long-term success of your practice.

What is Workplace Bullying?

Workplace bullying is a form of repeated aggression by one or more “perpetrators” upon one or more “targets.” Bullying is most often hierarchal (between a supervisor and employee) but can also be lateral (among co-workers) and the bully’s actions can be obvious or subtle, verbal or non-verbal.1 Bullying is driven by the perpetrator’s need to control the targeted individual, perpetrators typically co-opt others (either voluntarily or through coercion) in the bullying behavior, and the bully’s personal agenda takes precedence over actual work and undermines legitimate business goals. Bullying manifests in the workplace as verbal abuse, offensive conduct or behavior, and work interference (sabotage). Table 1 provides some common examples.

Table 1. Examples of Workplace Bullying

  • Intimidating a person through stated or implied threats.
  • Spreading malicious rumors or gossip that is not true.
  • Excluding or isolating someone socially, such as routinely not including an individual for company events.
  • Being short, curt, or impatient with the intention of limiting communication.
  • Undermining or deliberately impending a person’s work, such as moving items around, “misplacing” documents, etc.
  • Physically abusing, threatening abuse, or appearing to want to commit abuse.
  • Establishing impossible deadlines or requirements that will set up the person to fail.
  • Withholding training, resources, or time to develop the skills necessary to complete a task.
  • Withholding information, omitting from important meetings, or giving out wrong information.
  • Yelling, speaking sarcastically, or using profanity.
  • Critiquing a person persistently, either one-on-one or in front of others.
  • Making accusations of incompetence, despite a history of objective excellence.
  • Blocking applications for an individual’s training, transfers or promotions.
  • Enforcing “policies” inconsistently and creating multiple performance standards that hold one person accountable but not others.
  • Taking credit for someone else’s work.
Adapted from “Bullying vs. Harassment: Understanding the Physiological, Neurological, and Strategic Costs,” Scott Warrick, JD, 2011.


Who are Bullies and Their Targets?

The vast majority of workplace bullies are bosses (managers, supervisors, and medical directors) who are competitive and driven but lack emotional security. Bullies crave power and control, have a sense of superiority due to position but are often unsure of their own abilities, resent the success of others, and above all are threatened by a co-worker’s or employee’s show of independence.

While on might believe that the targets of workplace bullying are the same as schoolyard bullying – those who are loaners, weaklings, or physically different – actually quite the opposite is tru. Targets tend to be the most skilled individuals in a workgroup – the “go to” people whose promotion, special recognition, or confidence create envy in bullying supervisors.

Moreover, targets typically refuse to be subservient. This causes a problem for the bully who seeks to separate vulnerable individuals from the group and make them feel bad. When targets take steps to preserve their dignity – their right to be treated with respect – bullies escalate their campaigns of hatred and intimidation, gossiping and cliquishness, to wrest control of the target’s work using shame, humiliation, and domineering behavior.
Rarely can bullies be effective on their own – they need the help of others in isolating a target and perpetuating the bullying cycle. That’s why bully supervisors use other employees (called “cronies”) who will support and build a positive image that the boss is actually a capable, compassionate leader and that the target somehow “deserves” the treatment received.

Impact of Power Differentials in Urgent Care

Medical practices such as urgent care centers are particularly susceptible to bullying behavior because of their hierarchical structure of authority. Not only does academic medical training reinforce a “survival of the fittest” mindset – up to 70% of medical students experience workplace bullying while in medical school – it’s also well established that senior nurses frequently “break in” junior staff members.2 Of particular sensitivity to urgent care operators is the power differential between medical doctors and front-line staff:

  • Medical doctors frequently earn 10 times the pay of front-line staff.
  • Medical doctors have significantly more education than their team members.
  • The doctor must approve all patient care and is thus the “final authority” (bottleneck) in service delivery.
  • Medical doctors have greater social prestige, credibility, and respect from the outside.

These discrepancies can create an environment in which employees are afraid to question, clarify, or correct a physician’s request. Patient safety is severely affected by workplace bullying as almost half of all medical support staff surveyed by the Institute for Safe Medication Practices said they would rather keep silent than confront a hostile physician.3 Bullying compromises the ability of workers to function as a team, diminishes the quality of patient care, and unnecessarily risks patient wellbeing – which could contribute to malpractice lawsuits even further raising the costs of bullying in the workplace.

Workplace bullying affects patients in the health care setting as attention shifts from delivering services to worrying about how one fits in with co-workers, the value placed on one’s job by superiors, whether one is compensated or evaluated fairly, and one’s future within or outside the organization. This means when bullying is present, not only does a charge entry specialist have to worry about accurately coding the patient visit, but she has to worry whether her boss will berate her work or he/she is gossiping about her in the break room.

Even worse is when bullying behavior occurs in the open – within view of patients. One study cited an example of a hospital patient who witnessed one nurse insult another while administering medication. The patient became afraid the nurse would retaliate if he complained about the incident, knowing that he would be returning for more treatments and had previously experienced a stressed-out nurse improperly inserting a needle. In this situation, not only was workplace bullying taking place but it actually caused the patient to experience feelings, similar to a target patient to experience feelings similar to a target of workplace bullying.3

How Does Workplace Bullying Affect Employees?

Workplace bullying is very damaging because of its repetitive nature, with the average duration of abuse being about 22 months.4 This means that for a long period of time, targets, co-workers, and patients witness abuse, which leads to an overall unhealthy workplace.

Victims of repeated abusive behavior experience feelings that include shock, anger, helplessness, and vulnerability, as well an inability to sleep, loss of appetite, headaches, and general anxiety related to work. Longer-term, workplace bullying leads to the same health consequences as post traumatic stress syndrome – including heart disease, weight gain, and diminished cognitive capacity. The target’s feelings of frustration often are brought home, affecting enjoyment of family and social relationships. Victims become withdrawn, take frequent or extended leaves of absence from work, quit their jobs, or in the most severe cases – commit workplace violence or suicide.

As illustrated in Table 2, workplace bullying not only has a direct negative effect on the target but it also has a negative effect on the overall operation. Job turnover can cost 100% to 150% of an employee’s annual salary as a result of expenses related to recruiting, onboarding and training, service delivery disruption, and the loss of intellectual capital to competitors. Costs for existing employees escalate as absenteeism and health insurance claims increase and productivity and morale decrease. Because patients are able to notice changes in employees, the practice’s image also suffers – reducing the likelihood of repeat business and positive word-of-mouth.
Managers need to know exactly what’s occurring on the operation’s front-line, but witnesses to workplace bullying start avoiding abusive bosses and forego any communication that may bring a “shoot the messenger” response. To avoid standing out – and becoming targets themselves – employees buy-in to a “yes man” culture that questions mothing and agrees to everything regardless of how detrimental to the organization’s long-term success. Managers begin to lose touch with the day-to-day business, leading to decisions made based upon incomplete or inaccurate information.

Table 2. How Workplace Bullying Creates an “Unhealthy” Workplace

  • Increased stress resulting in increased absenteeism and turnover
  • Increased body weight, incidence of heart disease and other ailments contributing to higher health care costs
  • Increased costs for recruiting, onboarding, and training
  • Increased costs for employee assistance programs (EAPs)
  • Increased risk of accidents/incidents
  • Decreased productivity and motivation
  • Decreased morale and employee engagement
  • Decreased customer service and diminished patient experience
  • Decreased brand image, patient loyalty, and word-of-mouth referrals
Adapted from and other sources.


What Can Urgent Care Operators Do?

While 37% of those in the U.S. workforce claim to have been victims of workplace bullying and to have reported the incident, studies show that 62% of employers ignore these complaints.5 One of the likely reasons is that employers do not know how to respond. While bullying is “harassment” – unless it’s motivated by a legally protected status such as race, religion, national origin, sex, veterans status or physical disability in which case it becomes a civil rights issue – there is currently no federal law concerning workplace bullying. Likewise, while 21 states have proposed anti-bullying bills since 2003, none have yet to be enacted into law.6
Targets who tell their stories often face disbelief from co-workers, bosses, and Human Resources managers, who assume the abuse if “petty” or that the target is just a “problem employee.” Many targets are actually blamed for their situations, and because being angry, sad or fearful is simply “not allowed” at work, targets feel imprisoned, powerless, heartbroken, and confused (Table 3). Therefore, it is currently up to employers to recognize the importance of creating a bully-free environment and establishing an anti-bullying policy.
An urgent care operation’s anti-bullying policy should clearly define what bullying is and give examples of workplace bullying. One way to determine if particular behavior would be considered workplace bullying is to use the “reasonable person” test. Would most people consider the behavior/actions inappropriate?

The policy should list the consequences of instigating or contributing to workplace bullying as well as the responsibilities of both management and employees in taking corrective action. Everyone should sign an acknowledgement form stating that they have been made aware of the policy, will abide by its zero-tolerance standard, and understand that if they are a target of or witness to bullying behavior that they have a responsibility to express their views and concerns.

Having an anti-bullying policy on the books will not completely prevent a workplace bullying situation but acknowledging a problem exists will improve overall communication and circumvent some of the negative consequences of workplace harassment.

Table 3. Typical Employer’s Response

There is little a target can do to stand up to the bully on their own. Yet, sadly, the most common response of employers is that they ignore the problem. That could be because 40% of bullied employees never report it to their employers and only 3% file lawsuits.

  • Everything the bully does is arbitrary and capricious, working a personal agenda that undermines the employer’s legitimate business interests.
  • “Bullying” is never called such – to avoid offending the sensibilities of those who have made the bullying possible – but instead euphemisms intended to trivialize the bullying and its impact are used (including incivility, disrespect, difficult people, personality conflict, negative conduct, and ill treatment).
  • Human Resources tells the target that the harassment isn’t illegal and that the target and perpetrator will have to “work it out between themselves.”
  • Everyone – co-workers, senior bosses, HR – agree (orally, in person) that the bully is a jerk, but there is nothing they will do about it (and later, when the target asks for their support, they deny having agreed with him/her.)
  • The target’s request to transfer to an open position under another boss is mysteriously denied.
  • Employees eventually leave on their own, are forced out of their positions through unjust and manipulated performance appraisals, or resort to workplace violence.
Adapted from How to Bust the Office Bully: Eight Tactics for Explaining Workplace Abuse to Decision-Makers; Sarah J, Tracy, Jess K. Aberts, and Kendra Dyanne Rivera; Project for Wellness and Work-Life at Arizona State University, January, 2007.


  1. Workplace Bullying Institute. Accessed January 30, 2012.
  2. Stokowski LA. A Matter of Respect and Dignity: Bullying in the Nursing Profession. Medscape. Published September 2010. Accessed January 30, 2012.
  3. Vanderstar ES. Symposium on Workplace Bullying: Workplace Bullying in the Healthcare Professions. Journal of Employee Rights and Employer Policy. 2004. Chicago; Kent College of Law.
  4. Pappas S. Your Bullying Boss May be Slowly Killing You. Live science. January 12, 2012. Accessed January 30, 2012.
  5. Tracy SJ, Aberts JK, Rivera KD. How to Bust the Office Bully: Eight Tactics for Explaining Workplace Abuse to Decision-Makers. Project for Wellness and Work-Life at Arizona State University. January 2007. Accessed January 30, 2012.
  6. Healthy Workplace Campaign. Accessed January 30, 2012.
Workplace Bullying and its Costs to the Urgent Care Operation

Alan A. Ayers, MBA, MAcc

President of Experity Consulting and is Practice Management Editor of The Journal of Urgent Care Medicine