1. Section Editor(s): Donnelly, Gloria F. PhD, RN, FAAN, FCPP
  2. Editor-in-Chief

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In the 1970s and 1980s, at the height of the nurses' rights movement,1 I traveled the country teaching nurses to be assertive, to craft strong, reasonable responses, to calmly and respectfully disagree, and to stand one's ground particularly on issues of patient care and professional behavior. I taught nurses to become more body aware, to read their own stress signals, and to use them to respond assertively instead of slinking away or behaving aggressively. The simple rubric was to use "I" messages instead of "You" messages, that is, it was much more effective to say "I disagree with your approach and here is the evidence to support my approach" instead of "You are an idiot who will not even listen!" I painstakingly differentiated the behaviors expressive of nonassertiveness, aggression, and assertiveness and role-played them with nurse groups. In 1983, I authored a book, RN's Survival Sourcebook: Coping With Stress,2 emphasizing the foundational aspect of assertiveness in promoting nurse empowerment and health. There were many other nurses, Herman3 and Chambers Clark,4 who taught and published widely on the crucial communication skills nurses needed to successfully navigate the workplace. And here we are nearly 50 years later, dealing with an epidemic of incivility and bullying in health care organizations now struggling to create safe and healthy environments for both patients and staff. Did early efforts fail? What went wrong?

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This is my take-during the past few decades, the focus in health care organizations shifted from an interpersonal to a structural emphasis; that is, restructure the environment, create new rules or policies, and ultimately the work environment will shape changes in staff behavior. The elaborate strategies and rules of industrially based programs such as the Toyota Production System, Lean Management, and ethics hotlines promised to increase safety for patients, create efficiency, expose the offensive, and promote teamwork. At initiation and for a time, such efforts are enthusiastically embraced and moderately successful. Eventually, however, decrement sets in and problems resurface. While revising organizational systems and processes can help, ultimately, responsibility for self-care and behavior change rests with the individual nurse. The American Nurses Association5 has developed a comprehensive approach to creating healthier work environments by addressing structural, policy, and individual development issues. The ANA's Web site on Workplace Safety and Healthy Work Environments is worth the visit.


The communication and self-care skills needed by nurses should be an integral part of all nursing program curricula as well as ongoing staff development in health care organizations. The bottom line for creating healthier work environments is respect for self and others along with developing direct, confident communication skills. Self-change creates change in others and in the overall environment. Change your perceptions of and responses to difficult interpersonal interactions and change in others will surely follow-it's mathematical!


-Gloria F. Donnelly, PhD, RN, FAAN, FCPP






1. Fagin CM. Nurses' rights. Am J Nurs. 1975;75(1):82-85. [Context Link]


2. Donnelly G. RN's Survival Sourcebook: Coping With Stress. Oradell, NJ: Medical Economics Books; 1983. [Context Link]


3. Herman S. Becoming Assertive: A Guide for Nurses. New York, NY: D Van Nostrand; 1978. [Context Link]


4. Chambers Clark C. Holistic Assertiveness Skills for Nurses. New York, NY: Springer Publishing Co; 2003. [Context Link]


5. American Nurses Association. Healthy work environment. http://, Accessed December 8, 2016. [Context Link]