1. Section Editor(s): Carroll, V. Susan Editor

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Providing a "safe" environment for patients and their caregivers is nothing new. Even before The Joint Commission (TJC) mandated safety goals and a culture that supported these several years ago, hospitals and other healthcare institutions implemented clinical and environmental practices aimed at creating safe havens for care. Healthcare institutions build this culture on mutual trust, shared perceptions related to the importance of safety, and confidence in their preventive measures. And, although not unique to healthcare safety, a high level of professionalism has to exist here for us to achieve our goals. What does this mean?

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Simply put, professionalism is the conduct or qualities that define a profession or professional individual. All caring professions-medicine, nursing, social work, and the therapies-are characterized by the ongoing pursuit of knowledge, a sense of responsibility for human needs, peer accountability, autonomy, and altruism. The behavior of professionals, however, doesn't always conform to these ideals. Healthcare has a long, and not so proud, history of tolerating disruptive, disrespectful, intimidating, and bullying behavior. Although we'd like to believe that only physicians demonstrate these behaviors, nurses are often just as guilty. As many as 65% of nurses at a large medical center reported "frequent" bullying behaviors among co-workers (Townsend, 2012).


Horizontal violence and workplace bullying are hot topics in current nursing literature. This lack of professional behavior has been definitively linked to adverse clinical events, errors, and decreased patient satisfaction (Rosenstein & O'Daniel, 2005). It erodes job satisfaction and morale, which in turn increases absenteeism and staff turnover and decreases productivity, creating an additional financial burden for institutions struggling to maintain margins that allow them to survive in today's competitive arena. Nonprofessional behavior also poses a significant threat to patient safety when nurses are afraid to speak up to confront "bad" behavior and to advocate for their patients. As nurses become isolated from their peers or leave an institution, insufficient numbers of staff may be left behind and many of those may lack the experience, confidence, or knowledge to recognize patient problems and act quickly to solve them.


The Leadership Standards developed by TJC clearly place the burden for creating, implementing, and maintaining a culture of safety on the shoulders of healthcare leaders. Two elements of performance linked to their Leadership Standards tell us that (a) "Leaders develop a code of conduct that defines acceptable, disruptive, and inappropriate behaviors" and (b) "Leaders create and implement a process for managing disruptive and inappropriate behaviors" (TJC, 2010). But what can each of us-whether or not we hold a "leadership" position-do? How can each of us contribute to a culture of safety?


Implement a formal, clearly communicated Code of Professional Ethics or Professionalism. Use this multidisciplinary code to create respectful, trusting patterns of communication and to address disrespect, intimidation, and bullying. Set clear standards and expectations that hold individuals accountable for their professional behavior.


Encourage staff to report errors as well as behavior. A safety culture is built on information and data that are shared openly among groups. We can learn from errors; they allow us to identify barriers to safe practice and optimal care. Collect data. Evaluating outcome-related data doesn't simply close the loop with our accreditors and regulators, the process provides us with information we can use to change practice.


Support one another in creating a healthy work environment. Help one another address nonprofessional behavior directly. Identify problems clearly and communicate them at staff meetings or other forums. Be a role model. Support zero-tolerance policies in your work place. Communicate openly with your leaders. Use Situation-Background-Assessment-Recommendation (SBAR) tools to script positive communication with other disciplines. Give your all to demonstrate our professional values of integrity, compassion, respect, and excellence.




Rosenstein A. H., O'Daniel M. (2005). Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. American Journal of Nursing , 105, 54-64. [Context Link]


The Joint Commission. (2010). Comprehensive accreditation manual for hospitals: The official handbook. Oak Brook, IL: Joint Commission Resources. [Context Link]


Townsend T. (2012). Break the bullying cycle. American Nurse Today, 7 (1), 12-15. [Context Link]