1. Kupperschmidt, Betty R. EdD, RN


Rebecca groaned through another difficult day working with Susanne, an RN on the unit whose harsh speech, hostile attitude, and complaining made tough days at work even tougher. But when Rebecca thought about confronting her, a huge knot formed in her gut. It made her angry that this had been going on for a long time and no one had the courage to confront Susanne.


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Sadly, such hostility in the workplace is all too common. An article in Nursing Management reported a story about a nurse manager who spoke harshly to employees and was consistently unpleasant and disrespectful. Unit employees and even physicians were overjoyed when she retired (Sanford, 2004). A recent study found that the most frequent source of verbal abuse of nurses was other nurses. Researchersdecried the fact that nurses have been taught to grin and bear it rather than confront (Rowe & Sherlock, 2005).

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The November/December 2006 issue of The American Nurse reported the formation of a Conflict Resolution Panel to identify and address disrespect and conflict in the nursing workforce. One response has been the publication of articles and continuing education by the American Nurses Association (ANA) focusing on lateral nurse-to-nurse violence (Rowell, 2007).


Kathleen Bartholomew (2006), author of Ending Nurse-to-Nurse Hostility, notes that 60% of new RNs leave their first positions within 6 months because of hostility. She lists forms of hostility including nonverbal innuendo, verbal affront, undermining activities, and withholding information. Nurses' refusal to confront this violence adds to its virulence. Bartholomew places responsibility for hostility at the feet of ineffective supervisors and nurses' lack of confrontation skills.


What is the source of all this hostility? Sandra Wilson (2001) writes that "hurt people [people who have been hurt] hurt people." Hurt involves intentional or unintentional actions, words, and attitudes that cause wounds and injuries-not physical, but unseen soul scars. The wounds in turn can lead to bullying (Lewis, 2001) and incivility (Hutton, 2006). Hutton adds that incivility is thought to be more common among females, making the nursing profession a vulnerable target.


Regardless how it is titled, hostility is unethical and unprofessional and must be addressed. Provision 1.5 of the Code of Ethics for Nurses states that "each professional nurse has an ethical duty to resolve workplace conflicts" (ANA, 2001, p. 9).


As a Christian nurse, you may be wondering, "Can I confront disrespectful interactions from colleagues in a way that models Christlikeness, courage, respect for myself and others, and forgiveness? Do I have an ethical and scriptural mandate to do so?"


The answer to both questions is "yes"-through a model of carefronting.


What is Carefronting?

Caring: a good word!!


Confronting: an uncomfortable word?


Carefronting: a Christ-honoring word!!


The term "carefronting" originated with David Augsburger (1973) more than three decades ago. Augsburger identified that conflict is to be expected. It is the way we handle conflict that influences relationships. In carefronting, personal needs are integrated with the wants and needs of others to attain and maintain effective, productive working relationships.


Carefronting is a method of communication that entails caring enough about one's self, one's goals, and others to confront courageously in a self-asserting, responsible manner. Carefronting communicates with impact and respect in interpersonal relationships and work-related situations. It considers the failure to confront disrespectful behavior as dishonest communication, not kindness, because it negates the importance of relationships and goals. Silent withdrawal from disrespectful comments or behaviors is self-defeating because work relationships depend on open communication.


Carefronting is honest, courageous communication that states what should and must be stated (Kupperschmidt, 2006a, 2006b). It includes making "I" statements such as "I want and we both deserve to be treated with respect" or "We have an ethical imperative to treat each other and our coworkers with respect."


An underlying principle of carefronting is that professional nurses collectively share accountability for creating work environments consistent with the values of the profession, that is, environments infused with mutual respect. This principle is mandated in our professional Code of Ethics(ANA, 2001), and it is embedded in Christ's teaching about relationships.


In today's conflicted work environments, Christian nurses must embrace their ethical imperative to role-model effective carefronting and address conflicts from a platform of respect, forgiveness, and courage. In other publications, I discuss the concept of carefronting as a model for addressing conflict in the nursing workforce (Kupperschmidt, 2006a) and multigenerational conflict (Kupperschmidt, 2006b). In this discussion, carefronting is presented as a model specific for Christian nurses, in which respect and forgiveness are developed more fully and courage is added to the model.


Respect: Valuing Each Other

Respect is like oxygen.


Take it away and that is all I can think about!!


From a Christian standpoint, respect is valuing each individual as a person imprinted with the image of God, a person of inherent value (Genesis 1:26; Psalm 8:4-8). From a biblical perspective, respect, self-respect, and respect worthiness are frequently interconnected. God bestows respect and honor to his people and to those who are humble and seek him (Psalm 84:11, 138:6; Proverbs 3:34). Christians' relationships are to be characterized by respectfulness and esteem for others (Philippians 2:3-5; Colossians 3:12-17). A respect-worthy person is one who is honest, sincerely concerned about others, and treats others with respect.


Respect is an integral element of carefronting and a professional mandate. The Code of Ethics for Nurses states that nurses in all professional relationships practice with respect for the inherent dignity, worth, and uniqueness of all individuals (ANA, 2001). Examples of disrespectful behavior include coworkers' refusal to assist or answer questions, general rudeness, harsh speech, hostile attitudes, and thoughtless acts and behaviors. Conversely, respect is demonstrated as nurses validate the professional expertise of others and their importance to patient care. A culture of shared accountability for mutual respect is essential for professional nursing practice to flourish.


There is a growing body of nursing literature addressing respect. Bonnie Wesorick (1998), a Christian speaker and author, describes respect as the invisible bridge of healthy human relationships and connections. Respect is all about remembering that every person has a soul and thus is worthy of honor. She notes that giving and deserving respect in the workplace calls for continuous work. Wesorick stresses that an environment founded on mutual respect will say to potential recruits that this unit is a good place to work.


The research of Heather Laschinger and Joan Finegan (2004, 2005) demonstrates the importance of respect to nurse retention. They conceptualize respect as a moral principle that implies valuing another person's essential dignity and worth, a fundamental core value that shapes organizational behavior. Organizations rich with empowerment structures enhance nurses' perceptions of being treated fairly and respectfully.


Anthony DeLellis and Ronald Sauer (2004), authors and students of respect, conceptualize respect as an element essential for relationship satisfaction and for bringing good to human life. They challenge professional nurses to understand, write, teach, and role-model mutual respect as an ethical foundation of interpersonal relationships, especially in work-related interactions.


In light of Scripture and professional mandates, it behooves Christian nurses to ensure that we are respect worthy and offer respect to others. If you are struggling with respecting others at work, use prayer and study the biblical references offered in this discussion to help you move toward respect.


The Gift of Forgiveness

When I hurt as I've been hurt, I am beneath the other.


When I seek revenge as I've been hurt, I am even with the other.


When I forgive as I've been forgiven, I am above the other.


Researchers are studying the role of forgiveness in family dynamics, forgiveness as strategy to mend rips caused by corporate downsizings, and the relationship between forgiveness and health. A link is being discovered between failure to forgive and physical and emotional health, indicating that chronic anger is toxic.


In carefronting, forgiveness is a process that lets go of anger, blaming, and avoidance, a process that comes to terms with the past and allows it to be truly past, and a process that supports and fosters respectful, ethical professional relationships. The past is past. However, consequences can be reassessed, the future reopened, and relationships restored. The choice to forgive arises from within the character of the person needing to forgive.


What is the essence of forgiveness? Jesus offers the most profound picture of forgiveness when as he was being crucified, he said, "Father, forgive them [horizontal ellipsis]" (Luke 23:34). He shows us that we can forgive because we have been forgiven (Matthew 18:21-22) and tells us that if we don't forgive others, God won't forgive us (Matthew 6:14-15; Luke 11:4). He gave us the Holy Spirit to empower us to live as he lived, forgiving others when they hurt us (John 15-16). The Apostle Paul explains further in Ephesians 4:32 that we are to forgive one another even as God for Christ's sake has forgiven us.


Noted Christian pastor Charles Stanley (1991) writes that when we forgive someone, we give ourselves a gift. The gift of forgiveness means setting someone free from an obligation or debt owed because of a perceived or real injury. In this model, forgiveness involves three elements: an injury, a hurt interpreted as a form of rejection; a debt owed as a result of the injury; and forgiveness, a cancellation of the debt.


Stanley notes that trying to understand why professionals hurt each other is not the same as forgiving. It is easier to accept and forgive people who hurt us if we let go of the need to understand or change them. Christians are urged to embrace others as God embraces them, a God willing to give a second chance, a God who rebukes (carefronts) offenses, and offers forgiveness (Micah 7:18). Stanley (1991) advocates carefronting respectfully, accepting others as they are and restoring relationships where possible. He notes that true forgiveness is complete when we accept God's forgiveness, forgive others, and forgive ourselves.


Although David Augsburger's (1996) work addresses family and faith relationships, the principles apply to the nursing workforce. He presents forgiveness as a complex process in which one separates coworkers (the offenders) from the behaviors and views the behavior as a wrong choice to take a wrong action in a wrong direction. Fixing blame serves a limited purpose and thus should be replaced with assigning responsibility. There may be isolated cases of pure one-sided injustices, but in most work relationships, assigning the ratio of responsibility shows that a part of the problem belongs to both parties. Assigning responsibility moves toward recognition of joint participation in the creation and dissolution of the problem. Each nurse's willingness to appreciate and own his or her part in the work environment is an important part of forgiveness.


True forgiveness mandates addressing anger. Internalized anger reinforces damaged relationships, whereas anger owned and responsibly expressed can be resolved. Anger creates debts by making impossible demands, such as "it should never have happened; it must be undone." In forgiving, one gives up the right to make impossible demands.


Augsburger (1996) notes that when I deny that I am angry-that is, act as though the other person was not disrespectful, smile as though I was not hurt by disrespectful or uncivil behavior-and then fake it as if everything is forgotten, this is not forgiveness. Rather, it is a magical fantasy because anger must be owned and addressed. He believes that both parties must be willing to acknowledge their part in the conflict for the process of forgiveness to be complete.


Some nurses may be unaware, however, when they hurt others. In these instances, carefronting could be initiated with these words: "You may not be aware of this, but[horizontal ellipsis]." This allows coworkers to save face, opens communication channels, and moves toward professional, ethical relationships (Kupperschmidt, 2006b). As Christians, we choose to forgive, however difficult, realizing that the process may have to be repeated without a change in the other's behavior. In these cases, Stanley (1991) believes that when we forgive (give ourselves the gift of forgiveness), our countenance and attitudes will change, and others will see the change in us.


Can we learn how to forgive? Must both parties be willing to actively forgive for the process to be complete? The answer to the first question is "yes." One learns to forgive by being open and willing to learn, and by practicing forgiving. Authors tend to disagree on the answer to the second question. In one camp are those who contend that forgiveness is complete if one person is willing to carefront the offender from a foundation of respect, forgive the offender, and truly release the offender from the debt. Others, however, contend that both parties must remember the pain together and agree to forgive.


Perhaps the Apostle Paul provides the best answer to this question. In Romans 12:18, Paul writes that if it is possible, as much as it depends on us, we are to live at peace with everyone. In a very real sense, we as Christian nurses forgive because we are called to be peacemakers in our work settings.



Augsburger (2000) writes that forgiveness is an essential element for rebuilding relationships. Forgiveness is the interpersonal bridge frequently necessary to reconnect alienated coworkers. This interpersonal bridge is difficult to rebuild when both parties endeavor to hang on to past offenses. Prerequisites to crossing this bridge, therefore, include the willingness to see the other person as having worth and to release the painful past. Making things right or getting even is not always possible. Revenge is not a reward because it tends to boomerang, continuing the injury within the person seeking revenge. Thoughts of revenge can elevate blood pressure, ulcerate a stomach, and accelerate other stress-related symptoms. Furthermore, we are instructed not to take revenge (Leviticus 19:18). Forgiveness, a letting go of past offenses, may seem risky, but it may be the only antidote to the negative outcomes of conflict (Augsburger, 2000).


Gary Inrig (2005), writing about forgiveness from a pastoral perspective, points out that the character of God sets the terms of forgiveness for the Christian nurse. Inrig develops forgiveness as life essentials taught by Jesus. The first life essential comprises carefully defining perceived offenses. This does not mean excusing, ignoring, denying, or trivializing them. Rather, it means carefully defining offenses with as much objectivity as possible.


The second life essential involves courageous carefronting, face-to-face rebuking of the offense. Leviticus 19:17 and Galatians 6:1 tell us we are to rebuke frankly. Inrig (2005) shares that in Luke 17:3, the word rebuke derives from the Greek lexicon meaning "to speak seriously about, to speak directly to, to warn, and to holdaccountable for behavior." He writes that the goal of courageous carefronting is not to express anger, but to bring about restoration of the working relationship. Inrig believes that confrontation is not simply an internal process engaged in for personal benefit, but rather an interpersonal process engaged in for the larger good, such as the working relationships on the shift and unit. It is a process designed to benefit others who may be victimized or hurt if behavior is not carefronted.


The third life essential in Inrig's (2005) model consists of appropriately carefronting disrespect, that is, choosing the appropriate time and place for privacy. Inrig (2005) stresses the importance of speaking the truth in love and carefronting privately not publicly, and humbly not arrogantly and self-righteously (Matthew 7:3-5). The goal is to bring about ethical, respectful interactions. We rebuke (carefront) with the goal of restoration, not blame and shame. Inrig reminds us that forgiveness and winning back a colleague is about promotion of the community's well-being.


Finally, we are to carefront reluctantly not gleefully, and restoratively not punitively. Inrig believes that forgiveness is intended to be a bilateral (mutual) interpersonal process that moves both individuals toward reconciliation. In work-related communities, however, if mutual forgiveness is not possible (the offender is unwilling to acknowledge disrespectful behavior), we must commit to act in love, let go of the offenses, and allow God to work in the situation and with the offender. Scriptures to help us forgive and rebuild relationships include Mark 11:25, Luke 23:34, and Acts 7:60.



We choose to carefront; the cause is worth fighting for.


We courageously carefront; it's our ethical and scriptural mandate.


Some define courage as lacking fear in a situation that would normally generate fear. Others view courage as overcoming fear. Courage is the spirit or quality that enables one to keep up morale when opposed or threatened (Wikipedia, 2007). It means following one's personal ethics, being willing to speak and hear the truth, and being willing to accept the consequences.


There are many instances of courage in the Bible. God told Joshua to be strong and courageous because he (God) would go before Joshua and never leave or forsake him (Joshua1:6). David courageously faced the giant Goliath (1 Samuel 17). Many kings of Israel acted courageously in the face of disaster (e.g., 2 Chronicles 14:9-17, 32:1-23). In 2 Timothy 1:7 we are reminded that God has not given us a spirit of fear, but of power, of love, and of a sound mind. A distinctive of Christian courage is that it has its source in God and obedience to him.


What are the essential elements of courage? In their book The Courage to Act, Merom Klein, the founder of The Courage Institute, and Rod Napier, a business consultant, draw on examples of Fortune-500 companies to reveal five traits of courage. They define courage as speaking and listening for the express purpose of enhancing relationships. Their five traits of courage are a unique fit for carefronting.


Candor means speaking and hearing the truth. Scripture supports both (Ephesians 4:15). We cultivate courage when we speak the truth as we know it, dare to listen, make it safe for others to express their perceptions, and provide feedback in a way that allows others to save face. Candor involves choosing a starting point for the confrontation and making comments personal, relevant, and explicit. Klein and Napier (2003) echo Inrig's (2005) belief about carefronting for the sake of the community, asking, "Who has not taken heart when another has had the courage to speak out, paving the way for their own foray into a high-risk arena"? (p. 41).


Purpose refers to purposefully pursuing professional goals and focusing on results and personal accountability. People with purpose are willing to do what it takes to change behavior in a way that enhances relationships. They decide what they stand for (respectful, professional interactions). Then they purposefully practice stepping back, looking at the big picture, and respectfully stating what should be obvious. They are empathetic in a way that does not let disrespectful peers off the hook and compromise desired results.


Having the will to carefront is an important part of courage, that is, realizing the importance of carefronting and committing to do it. The will refers to making confrontation personal, relevant, and explicit. Courage is cultivated as nurses view themselves as part of a community and acknowledge that important goals may be unobtainable without the cooperation of each nurse. Klein and Napier (2003) point out that when one team member rises to the occasion to speak the truth, this gives others' hope that the disrespectful behavior will end and/or that he or she can reciprocate with courageous carefronting.


Rigor means having the discipline to plan for effective carefronting: to make optimal use of resources, to say what one will do, and to do what one says. We cultivate rigor, and thus courage, by putting personal convenience in perspective, letting logic prevail, and ensuring that we are not blaming and shaming.


Risk is willingness to do what is needed to resolve conflict. Klein and Napier (2003) assert that we cultivate risk when the key questions become, "What's best for the team?" and "What is best for patients?" We cultivate risk by trusting the goodwill of others and investing in relationships with a sense of responsibility and respect. We control disappointment and risk by interacting face-to-face while simultaneously considering the needs of those who offend us. We conduct ourselves in a way that earns trust, doing what is right rather than what is convenient. We risk by showing empathy and being willing to listen and reassess the situation.


Klein and Naper (2003) note that professionals tend to view themselves as having a kinship with the person who needs help: Even after repeated disrespectful behaviors, the offenders are valued as professional colleagues. Work group cohesion is an important aspect of cultivating courage. Cultivating a team norm for the five factors can imbue individual nurses with a greater level of courage than they would exhibit if they were working alone. The authors believe that helping disrespectful coworkers by caring and respecting them enough to carefront is a moral and possibly a religious imperative. They ask, "If I have to answer to a higher power for my moral acts or decisions not to act, how can I justify failing to do the right thing, whether or not I will receive a tangible personal benefit or reward?" (p. 183).


Where do I begin?

As a Christian nurse, you begin carefronting with prayer, as instructed by Jesus (Matthew 5:44-48). The process also begins with the heart by clarifying what you want for yourself, the other person, and the relationship, and it continues with being frank yet respectful (Patterson, Grenny, McMillan, & Seitzler, 2002). When confronted with disrespectful behavior, ask the question, "Why would a reasonable, rational, decent person say or do that?" This strategy reportedly puts the brain into a more empathetic, positive, problem-solving mode (Patterson et al., 2002). Following this recommendation, a Christian nurse might ask, "Why would a nurse created in God's image with inestimable worth and value do or say that?" This helps put the brain, soul, and spirit into a Christ-honoring mode, a mode willing and able to carefront the behavior and, hopefully and prayerfully, usher in respectful interactions.


Three reasons victims of repeated disrespect might fail to carefront include being too proud to go to the other person, believing that carefronting is too painful or risky, and not understanding how to carefront and forgive. These reasons parrot those of staff nurses who report they chose not to confront nursing colleagues' unacceptable behaviors for fear of damaging the relationships, engendering further hostile acts, and triggering refusal to provide needed assistance (De Marco, 1998). In Christ, we find answers to these concerns. We are called to be humble, gentle, and patient with others (Ephesians 4:2), to be like Jesus in humility and obedience (Philippians 2), and to trust in God when afraid (John 14:1).


In our multicultural society, it is important to remember that in some cultures confrontation or open discussion of matters of conflict is considered inappropriate and therefore avoided. Nurses from such cultures may not carefront because of their cultural beliefs. When approaching conflict with nurses from other cultures, keep their cultural background in mind and choose your carefronting words carefully.


Imagine a workplace in which nurses care enough about themselves, their peers, and their coworkers to confront disrespectful behaviors courageously and respectfully and to forgive, even if carefronting is not received and behavior changed. Begin taking steps to use candor, to pursue professional purposes for patients and coworkers, to have the will to confront graciously, to apply rigor to needed settings, and to risk asking key questions to move toward resolution. Carefronting helps nurses assess the work environment and make needed changes. Why not ask God to help you be the first in your workplace to start carefronting.


Case Study in Carefronting

Sandy, a new nurse on the unit, noticed that Gerry, a colleague who worked the shift after her, frequently came out of report at shift change criticizing her patient reports. Report was "taped" for the oncoming shift using a voicemail system, and the oncoming shift nurses had no opportunity to ask questions of the reporting nurse.


Gerry would walk out of report and publicly say things such as "Sandy, your reports are too long; you need to cut out the fluff," or "I wish you would just get to the point." When Sandy tried to condense her reports, Gerry announced, "You need to tell us what's going on. How am I supposed to know these patients?"


Sandy began feeling a knot in her stomach every time she went to record report, a knot that tightened when she saw Gerry arrive on the floor. Other staff who noticed the criticism said to Sandy, "Don't worry about Gerry. She gripes about everything. Just take it with a grain of salt."


Sandy decided she had to take her feelings and her colleague to Jesus in prayer. She asked God to soften her heart toward Gerry and show her any "logs" in her own eye-areas where God wanted to work in her heart and life (Matthew 7:1-5). Sensing that Gerry's response to her might be part of a bigger problem with unhappiness in Gerry's life, Sandy asked God to show his love to her colleague, show her how she could help Gerry, and help her resist the temptation to gossip.


Sandy also prayed that God would show her what was most important in this situation. Sandy identified 1) that she wanted Gerry to stop the critical comments, 2) that she wanted to give adequate shift reports, and 3) that the reports she heard from other nurses could be more helpful to her, especially when she didn't know a patient.


Sandy decided she needed to talk to Gerry before another incident of criticism occurred (not when it occurred and she became flustered), so she checked the work schedule to see when she and Gerry would next work on the same day. When that day arrived, Sandy took a deep breath, prayed silently, and asked Gerry if she could talk to her for a moment in the med room (for privacy).


Sandy began, "Gerry, I've noticed there are times when my reports are not as helpful to you as I would like them to be. There are times when I would like report to be more helpful to me as well. To offer the best patient care, I'm wondering if you would be willing to meet together with Jill (the nurse manager) to help formulate some guidelines for everyone to use when taping report. We can work out the details for this at another time, but I wanted to present the idea to you."


Gerry responded, "I don't think all that is necessary. You just need to work on your reports." Sandy replied, "I plan on doing that, but I have a request. You may not be aware of this, but when you critique my patient reports in front of everyone, I feel embarrassed and disrespected. We both deserve respect, so could I ask you to stop doing this?" Gerry was ruffled and offered excuses for her behavior, but Sandy kept making "I" statements and stuck to her request. Gerry eventually agreed to stop criticizing Sandy's reports.


The next week, Sandy showed Gerry an outline she had developed to use when recording patient reports. Gerry thanked her and told Sandy her reports were getting better.-KSS


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