1. MacLean, Loriann MSN, RN
  2. Coombs, Charmaine MSN, RN
  3. Breda, Karen PhD, MSN, RN

Article Content

It's a make or break moment: Anne, a new nurse manager, enters her unit and witnesses the charge nurse yelling at Mike, a graduate nurse. She then sees Mike lower his head and walk away. How Anne addresses this situation will sketch the framework of her management style, establish her credibility with other employees, and determine her ability to govern the unit and effectively lead.

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Incivility and bullying exist at all levels of healthcare delivery, interfering with the clinical learning process and costing organizations billions of dollars.1 Historically, supervisors minimize bullying in the workplace; victims and observers who ignore signs of bullying or other bad behaviors are contributing to the continuation or worsening of these behaviors.2 According to The Joint Commission, "Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it."3


Vicious cycle

Bullying can be defined according to its direction. Employee-against-employee violence, such as nurse-on-nurse bullying, is categorized as horizontal or lateral violence, whereas vertical violence is bullying directed from the top down, which includes employers against employees (unfair work practices, abuse of power, and so on). Bullying can also occur from the bottom up, such as employees against employer (work slowdowns, mass call outs, refusals to follow procedural changes, and so on).


Mobbing is another type of violence, characterized as collective bullying or "ganging up" on a targeted individual with the aim of expelling the individual from the group or controlling/intimidating the individual into maintaining the status quo by possibly using such group tactics as sabotage, slander, petitions, or even votes of no confidence.4


The cycle of lateral violence has gone on for so long, in part, because it's surrounded by a culture of secrecy, with the victims and observers experiencing real fear of being retaliated against and ostracized. There's also a feeling that lateral violence is a condoned part of nursing-a rite of passage, even.5


As a leader, have you witnessed toxic workplace behaviors, such as eye rolling, sarcasm, or threats? What about aggression; withholding pertinent patient information/sabotage; disrespectful, rude, or condescending comments; or scapegoating? These actions are incivility, lateral violence, and bullying-all precursors to workplace violence.


Incivility, part of a larger group of harmful behaviors, has affected the work environment for decades, yet it continues. One study found that nearly 85% of nurses experienced workplace incivility in the last year, whereas almost 37% admitted to instigating workplace incivility. Nurses didn't believe their managers had the ability to handle workplace incivility situations.6 For this very reason, organizational leaders need to partner with managers to practice and support civil behavior in the work environment.1


Although the nursing profession's philosophy has always been one of kindness, caring, and nurturing, it's now also considered the primary occupation for bullying.7 Nursing regulatory bodies have outlined the foundation of professional conduct, with similar expectations for professional standards. The American Nurses Association (ANA) has combined these expectations into its Code of Ethics for Nurses. This document aligns with the ANA's prevention framework and defines the importance of accountability for one's actions and conduct of professionalism, which "serves as a foundation that directs professional behaviors for nurses when caring for patients and interacting with other healthcare professionals."8 The Code requires nurses to exhibit a culture of respect, and they're encouraged to partake in efforts to maintain and improve a healthy work environment.8 Bullying, harassment, intimidation, manipulation, threats, and violence are identified as morally unacceptable behaviors.9


In 2015, the ANA released a position statement on incivility, bullying, and workplace violence. The statement's purpose was to express the shared responsibilities of employers (organizations and management) and employees (nurses) to create an organizational culture built on respect without incivility, bullying, or workplace violence. Healthcare leaders are expected to maintain a safe work environment for all, and nurse managers are expected to role model civility and professional conduct.1 By implementing the best practice strategies that the ANA outlined, incivility, bullying, and workplace violence will be prevented while the health, safety, and wellness of nurses will be promoted.8


The ANA's approach

The ANA used a three-tier prevention framework to guide its recommendations for addressing workplace incivility: primary, secondary, and tertiary prevention. Nurse leaders can effectively address uncivil workplace behavior by using this same trilevel preventive approach. Leadership goals for primary prevention include identification, education, and communication. Secondary prevention focuses on harm reduction once the incidence has occurred, whereas tertiary prevention concentrates on reducing the ensuing fallout and escalation post event.8


Primary prevention

Nurse leaders can ensure that their organizational vision, mission, and philosophy support a culture of respect that's known to employees. Leaders can develop policies and procedures regarding safe and civil work environments, including professional communication and zero-tolerance for incivility, bullying, workplace violence, and retaliation. Employers can help eliminate bullying by providing documented ongoing staff education, a mechanism for reporting and investigating such incidences, and consequences for nonadherence to policy and procedures.8


When nurses complete their professional structured education, the baton is passed to the nurse managers and executive leadership team to reinforce expected professional conduct. Nurse administrators are encouraged to bring civility best practices to life by role modeling professional behaviors and facilitating organization-wide educational campaigns to improve professional relationships via communication, as well as reinforce professional demeanor and positive norms.2


Organizations are encouraged to provide intensive multidimensional education to clearly identify and define uncivil behaviors and bullying, with vivid demonstration of these untoward behaviors' effects on patient safety, unit stability, staff retention, staff illness/ sick calls, unit morale, individual nursing practice, and the overall nursing profession. Part of this campaign may include collaboration with nursing staff to develop a motto or code words that serve as a reminder and stimulate appropriate action. Slogans such as "civility now," "code pink," and the "ouch campaign" are a few examples. Nurses can be educated and encouraged to use the code words when they feel bullied or threatened, or if they witness unprofessional workplace conduct. The individuals to whom the code word is directed are prompted to immediately cease and desist the unprofessional behavior.8


Going back to the scenario at the beginning of this article, when the charge nurse was yelling at Mike, the graduate nurse, several nurses overheard it. Mike, himself, or one of the other nurses could've intervened by using their established code word. When the code word was spoken, all available nurses in the vicinity could've stood next to Mike to show support and signal to the charge nurse to stop her unprofessional behavior immediately.


Another portion of the educational campaign is to prepare nurses to stand up to bullying by teaching predetermined rehearsed phrases to use in case of exposure to incivility or bullying, a process known as cognitive rehearsal.4 For example, Mike should approach the charge nurse and say something to the effect of, "Can I talk to you in the break room? I really appreciate you agreeing to precept me at the last minute in addition to your other responsibilities; I've learned a lot from you so far. There were nurses, patients, and visitors around when you yelled at me, which is embarrassing and not a good professional look for any of us. You have so much experience, and I want to keep working with you, so if there's something I need to correct, please address me personally and privately."


Secondary prevention

Once the incident has occurred, the goal for nurse leaders is to reduce harm and prevent any further occurrences. After bullying is reported, the organization should activate the established ANA tools by conducting an investigation of the incident to obtain information regarding the type of bullying, the incident's severity, and the parties involved, all while using the organization's policies, protocols, codes of conduct, and previous staff education as a guide to formulate and implement an action plan to address the specific incident.8 Regarding this article's bullying scenario, other staff members were present, in addition to nurse manager Anne, when the charge nurse yelled at Mike. If bullying incidents are observed by other staff members, then a debriefing session may be warranted; witnessing these events may have traumatizing effects on some staff members.


Once the investigation is complete, another way to reduce harm involves instituting corrective measures to prevent any further instances, copycatting behavior, or retaliation. Leaders should provide guidance and support for staff by assessing areas of vulnerability in themselves and their employees, and focusing on applying measures to reduce stress and fatigue, encourage self-care, and offer training to improve psychological resilience and coping skills.8


It's also important to identify collateral contributing factors because this information can be a major catalyst for the bullying incident and proves instrumental in stopping the cycle of incivility.2 For example, are fatigue, increased workload, and/or changes in your organization's management or policies contributing factors? In our case scenario, the charge nurse worked 4 days in a row, including a double shift the day before the incident due to call outs. She was given a seven-patient assignment instead of the usual five, and was expected to precept Mike because his preceptor called out sick.9


Tertiary prevention

The goal of tertiary prevention is to reduce the ensuing fallout associated with incidents of incivility, bullying, and workplace violence. Nursing leadership's position can ensure a transparent investigation process, allowing all parties to know what to expect and designating a neutral third party to meet with everyone involved. Leaders can maintain detailed documentation and monitor behaviors in case a pattern emerges, and then establish a performance improvement plan for the individual engaged in unprofessional conduct. The improvement plan can include a determined time frame to demonstrate a change in behavior without retaliatory action. The ANA recommends that leaders establish a committee to provide support and explore other possible intervening measures. The committee's purpose can also be to keep the issue on the forefront of the hospital's agenda.8 In addition, recommendations offer leaders the opportunities to increase their presence and visibility in the clinical areas, in addition to actively listening to staff concerns.10


How can Anne, the nurse manager, react to witnessing the charge nurse yelling at Mike, the new graduate nurse? According to the ANA's recommendations for bullying and lateral violence, Anne's possible response may be to approach the charge nurse and ask to speak to her in private. Once in a private area, Anne can say, "I saw and heard you yelling at Mike; he walked away with his head down. I don't think he appreciated being talked to like that, especially in front of others. It sets a bad example for the staff and doesn't leave a good impression on patients and their family members. If there's something you need to discuss with Mike, please do so respectfully and in private. I know this is a very busy unit and it can become stressful at times. Take care of any immediate issues now, and then give report to one of the other nurses so you can take a 10-minute break off the unit. Please make an appointment to see me this week so we can further discuss this matter and, until then, think of other ways you could've handled that situation."11


Nurse leaders can review organizational policies regarding civility and code of conduct in the workplace, in addition to the organization's procedure for handling incidents of incivility and available resources. Nurse leaders can also review scenarios with staff and role play other possible responses for dealing with stressful and frustrating situations in a professional manner.


Clear, consistent responses

For nurse leaders to be effective in addressing workplace incivility, they must have the tools to be competent. Organizations are encouraged to incorporate the ANA's 2015 Position Statement on Incivility, Bullying, and Workplace Violence prevention recommendations into their policies, establish an ongoing code of conduct, provide education to staff on professionalism and civil behavior, and facilitate consistency in the enforcement of policies and clear procedural guidelines for dealing with uncivil behavior. Nurse leaders need to be encouraged to be assertive, and to develop conflict resolution capabilities and negotiation skills. Organizations that offer education and support to their nurse leaders will be better prepared to effectively address uncivil workplace conduct.




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