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Nursing practice and work environment


Bullying has long existed in health care; it was the ugly secret that no one wanted to talk about. However, the culture of acceptance and silence that accompanied it is finally being broken. The conversation is changing to focus on creating civil cultures that embrace collegiality and respect.

In society, the problem of bullying is insidious and ranges from the subtle to the obvious. It starts early in childhood as a learned behavior and becomes a cycle reinforced in later educational environments and the workplace. There is a systemic nature and complexity to the phenomenon resulting in the need for a comprehensive, experiential, and evidence-based approach to eliminating it from health care. Over the last 5 years, the literature has exploded with evidence-based contributions that address the incivility experience and its relationship to lost human capital and impaired patient outcomes.

Based on this evidence, several professional and accreditation organizations published principles, recommendations, and position statements to support bullying prevention in the workplace (American Nurses Association [ANA], 2012, 2009, 2006; American Association of Critical Care Nurses, 2005; American Organization of Nurse Executives, 2014; The Joint Commission, 2008). However, harmonizing the cultural, generational, gender, and professional differences in a healthcare culture filled with authority gradients increases the challenges to overcoming the bullying problem.

ANA’s 2015 position statement

In August, ANA introduced a new resource for nurses at every level of practice to identify, understand, differentiate, intervene for, and evaluate bullying in all settings. The ANA Position Statement on Incivility, Bullying, and Workplace Violence explores and defines the importance of actions for the individual and the employer. ANA recognizes that these issues occur along a continuum and are connected on many levels with similar solutions, but that they also may require different interventions on behalf of the individual and employer. The position statement is a call to action to individuals and organizations that is supported by evidence and resources. The position statement is available at http://goo.gl/VIlu6G.

PACERS Civility Toolkit

Another resource is the new Civility Toolkit: Resources to Empower Healthcare Leaders to Identify, Intervene, and Prevent Workplace Bullying. The toolkit was created and deployed by a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows project team called the PACERS– Passionate About Creating Environments of Respect and civilitieS. The team offers a variety of tools to assess, implement, evaluate, and assist in culture recovery. The toolkit was built on the socioecological model, which provides a foundation to examine the problem and create actionable tools from the individual to the policy level. Recently added to the toolkit were free training videos and a guide for teaching students and providers to hold respectful conversations in difficult situations. Learning to hold these conversations to address incivility and bullying takes practice. It is a skill to be mastered, just like learning to take blood pressure, completing a history and physical examination, or writing a business plan. Access the toolkit at stopbullyingtoolkit.org.

A systematic approach

The solution to the problem of incivility and bullying in the workplace involves a systematic approach in which each individual, group, organization, and system takes action to eliminate the conditions that promote bullying, the structures that maintain it, and the norms that support it.

Cole Edmonson is chief nursing officer for Texas Health Presbyterian Dallas in Dallas, Texas. Beth Bolick directs the acute-care pediatric nurse practitioner program at Rush University in Chicago, Illinois. Both authors served on ANA’s Professional Issues Panel on Incivility, Bullying, and Workplace Violence; Edmonson was a co-chair of the steering committee; Bolick served on the advisory committee. In addition, both authors are RWJF Executive Nurse Fellows and members of the project team that developed the PACERS Civility Toolkit.

Selected references
American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2005. aacn.org/wd/hwe/docs/hwestandards.pdf

American Nurses Association. Bullying in the Workplace: Reversing a Culture. Silver Spring, MD: Nursesbooks.org; 2012.

American Nurses Association. Lateral Violence and Bullying in Nursing. 2009. nursingworld.org/Content/NavigateNursing/AboutNN/Fact-Sheet-Lateral-Violence-and-Bullying-in-Nursing.pdf

American Nurses Association. Position Statement: Incivility, Bullying, and Workplace Violence. 2015. nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence/Incivility-Bullying-and-Workplace-Violence.html

American Nurses Association. Resolutions: Workplace abuse and harassment of nurses. 2006. nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/WorkplaceAbuseandHarassmentofNurses-1.pdf 

American Organization of Nurse Executives. AONE Guiding Principles: Mitigating Violence in the Workplace. 2014. aone.org/resources/guiding-principles-violence-in-the-workplace.shtml

Bolick B, Edmonson C, Adeniran R, et al. Respectful conversations for difficult situations. Facilitator guide and videos. Civility Toolkit: Resources to empower healthcare leaders to identify, intervene, and prevent workplace bullying. 2015. stopbullyingtoolkit.org

McLeroy KR, Steckler A, Bibeau D. eds. The social ecology of health promotion interventions. Health Educ Q. 1988;15(4):351-77.

The Joint Commission. Sentinel Event Alert. Issue 40; July 9, 2008. Behaviors that undermine a culture of safety. jointcommission.org/assets/1/18/SEA_40.PDF

Editor’s note: See related article in this issue: “Conversations to inspire and promote a more civil workplace.”

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