Incivility Discussion Board
638 December 2012 • Volume 16, Number 6 • Clinical Journal of Oncology Nursing
Stopping the Culture of Workplace Incivility in Nursing
Professional Issues Guadalupe Palos, RN, LMSW, DrPH—Associate Editor
Rachele E. Khadjehturian, RN, MSN, FNP-BC
Workplace incivility (WI) continues to hamper professional nursing practice, patient care, and the health of nurses who encounter this phenomenon in their workplace. This article provides an exemplar of WI experienced by a new nurse when a more seasoned nurse uses humiliation, intimidation, and angry verbal abuse to accuse the novice nurse in the presence of coworkers and patients that she failed to provide essential nursing care to a challenging patient. Nurses are reminded that open communication among coworkers will help minimize the occurrence of WI, encourage a supportive milieu in the unit, and ensure the safety of patients, family, and staff.
Rachele E. Khadjehturian, RN, MSN, FNP-BC, is the program director of the New Graduate Nurse Residency Program at New York-Presbyterian University Hospital of Columbia and Cornell in New York, NY. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Khadjehturian can be reached at rad9037@nyp.org, with copy to editor at CJONEditor@ons.org.
Digital Object Identifier: 10.1188/12.CJON.638-639
N urse-to-nurse workplace incivility (WI) continues to hamper profes- sional nursing practice, patient
care, and the overall health of nurses who encounter this phenomenon in their workplace. The literature presents other terms used to describe this phenomenon, including horizontal abuse, bullying, vertical abuse, and nurses eating their young (Ceravolo, Schwartz, Foltz-Ramos, & Castner, 2012; Embree & White, 2010; Farrell & Shafiei, 2012; Hutchinson, Vick- ers, Wilkes, & Jackson, 2010; Sheridan- Leos, 2008). In addition, strong evidence exists demonstrating WI contributes to increased turnover rates, diminished job satisfaction, and decreased patient safety because of poor communication among workers (Center for American Nurses, 2008; Johnson & Rea, 2009; Joint Com- mission, 2008; Sheridan-Leos, 2008). One study reported that nursing units normalized WI when the supervisor was the source of the abuse (Hutchinson et al., 2010). Notably, in a study conducted by Ceravolo et al. (2012), nurses in units that normalized WI often were not aware of their destructive actions because the behavior was so widely accepted.
The purpose of this discussion is to raise readers’ awareness of the continua- tion of WI in nursing and to outline tips to address this type of destructive behav- ior in a prompt and proactive manner. For the purpose of this article, WI has been defined as a consistent behavior used to degrade or control another’s be- havior, including individuals or groups (Farrell, 1997, 1999).
Case Study The following case study is an exem-
plar of nurse-to-nurse WI experienced by a new RN. In this situation, a more seasoned nurse used humiliation, in- timidation, and angry verbal abuse to accuse a novice nurse, in the presence of coworkers and patients, that she failed to provide essential nursing care to a chal- lenging patient.
Nurse X was hired at her first nursing job as a new graduate nurse onto a busy inpatient oncology unit at a prestigious academic medical center. She had no previous healthcare experience, and her bachelor’s degree in nursing was a sec- ond degree for her. She had completed
orientation recently and had worked for a few weeks when she shared this recent experience.
We have one patient on our unit
who is very challenging to take care
of, as she is known to manipulate
people and situations. I happened to
be assigned to be her nurse for three
days in a row despite requesting an
assignment change after day one. At
6 am, nearing the end of my second
shift with her, I asked the patient to
try to use the bedpan (she tends to re-
quest a bedpan at 7:15 in the middle
of change of shift) but she refused.
At 6:45 I asked her again, and [she]
refused. At 7:15, I was at the nursing
station giving report to the RN com-
ing on duty. I had already handed
my beeper off to the day shift and,
therefore, was not made aware of
the call bells that came into the unit
clerk. A few minutes later, a fellow
night shift nurse stormed into the
nurses’ station where I was sitting
and began to scream at me in front
of medical residents, patients, and
RNs from the day and night shifts.
She demanded to know why I was
neglecting my patient and saying it
wasn’t her job to take care of her.
. . . I tried to reason with her calmly
but she just kept screaming at me,
and then began to proclaim her be-
lief of my incompetence in front of
everyone. No one stood up for me or
said anything to the nurse that was
yelling at me. I left that morning in
tears. Needless to say, I was dreading
coming in the next day, not only be-
cause I knew I would have the same
assignment, but also because I would
have to work with the same people.
The author’s first response to the new graduate’s story was dismay and
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Clinical Journal of Oncology Nursing • Volume 16, Number 6 • Professional Issues 639
distress. Sadly, she was not surprised. Many nurses have shared similar stories describing destructive behavior such that WI was considered the norm rather than the exception. The culmination of this event and many others prompted the first publication, “Combating Lateral Violence in Nursing: 10 Steps to Being a Colleague Advocate,” in the Oncology Nursing Soci- ety Management and Program Develop- ment Special Interest Group newsletter (Khadjehturian, 2012). The companion piece is an exemplar and tips to address the specific issues are presented using the guidelines set forth in the original article (see Figure 1).
Nurses must consciously decide to stop this destructive conduct before it destroys nursing as a profession. In 2008, the Center for American Nurses released a statement on WI to educate the nursing profession of this dangerous phenomenon and its harmful effects on nurses (Center for American Nurses, 2008). Such aggres- sive behavior also threatens patient safety, which prompted the Joint Commission to include standards against bullying in the workplace in their accreditation process. The standards call for the workplace to have a code of conduct to address disrup-
tive behavior and a process to manage such harmful behavior ( Joint Commis- sion, 2008). With the new Affordable Care Act going into effect in the United States, nurses will have more responsibility than ever before to ensure patient safety. Nurs- es will have to work together to ensure that communication between veteran nurses, new graduates or novice nurses, and other members of the healthcare team is collegial, respectful, and helpful.
Nurses must remain aware that WI con- tinues to threaten nurses and the nursing profession. They must educate themselves on best practices to address these harmful situations in a prompt and proactive man- ner. Nurses also must remind themselves that regular assessments and open com- munication among coworkers will help minimize the occurrence of WI; encour- age a supportive milieu in the unit; and en- sure the safety of patients, family, and staff.
u New nurses may not feel comfortable standing up for themselves when faced with hostility from a seasoned nurse. Be a source of support by talking, listening, asking for clarification of situations, and being a mediator if asked and when ap- propriate.
u Strong teamwork, high morale, and effec- tive communication may be created and maintained by having team meetings at the beginning of each shift to establish nurses’ concerns and patients’ needs.
u Physical proximity creates a supportive environment. Do not walk or turn away if you see bullying. Stand behind the victim physically and figuratively to show solidar- ity. Ensure the nurse manager is aware of the event and that witnesses come forward.
u Disruptive behavior must be stopped right away. To better prepare staff to deal with such behavior, work with the nursing edu- cation department to implement programs
FIGURE 1. Tips to Avoid Workplace Incivility in Nursing Note. From “Combating Lateral Violence in Nursing: 10 Steps to Being a Colleague Advocate,” by R.E. Khadjehturian, 2012, Oncology Nursing Society Management and Program Development Special Interest Group Newsletter, 23(2), p. 3. Adapted with permission.
References Center for American Nurses. (2008). Lat-
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Ceravolo, D.J., Schwartz, D.G., Foltz-Ramos,
K.M., & Castner, J. (2012). Strengthening
communication to overcome lateral vio-
lence. Journal of Nursing Management,
20, 599–606.
Embree, J.L., & White, A.H. (2010). Con-
cept analysis: Nu rse-to -nu rse lateral
violence. Nursing Forum, 45, 166–173.
doi:10.1111/j.1744-6198.2010.00185.x
Farrell, G.A. (1997). Aggression in clinical
settings: Nurses’ views. Journal of Ad-
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Farrell, G.A. (1999). Aggression in clinical
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Farrell, G.A., & Shafiei, T. (2012). Work-
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K hadjehturian, R.E. (2012). Combating
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that teach the skills and confidence need- ed to manage unacceptable behaviors.
u Experienced nurses in these scenarios need to be made aware of how their disruptive behavior is affecting others on the unit. Self-awareness allows nurses to identify these behaviors in themselves and explore more positive reactions to stressful situations.
u Nurse managers lead by example when they support bullied staff and reas- sure them the issue is being addressed through appropriate channels. A bond of trust will be created when a situation is brought to a manager and dealt with directly.
u Make a zero-tolerance policy for any bullying or aggression and re-emphasize support for the policy regularly to change the culture. Underscore the staff’s respon- sibility to maintain a high-quality and safe environment for patients and each other.