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CNE ​ Incivility and Bullying

Continuing Nursing Education (CNE) Credit
A total of 2 contact hours may be earned as CNE credit for reading “Incivility and Bullying in the Workplace and Nurses ’ Shame Responses,” and for completing
an online post-test and evaluation.

in the Workplace Shame Responses

Dianne M. Felblinger 1​

and Nurses ’
AWHONN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
ABSTRACT
AWHONN also holds California and
Incivility and bullying in the workplace are intimidating forces that result in shame responses and threaten the well- ​Alabama BRN numbers:
California CNE provider #CEP580 and
being of nurses. Some nurses are accustomed to tolerating behaviors that are outside the realm of considerate ​Alabama #ABNP0058.
conduct and are unaware that they are doing so. These behaviors affect the organizational climate, and their
http://JournalsCNE.awhonn.org
negative effects multiply if left unchecked. Interventions for incivility and bullying behaviors are needed at both individual and administrative
levels.
JOGNN, 37, 234-242; 2008. ​DOI: 10.1111/j.1552-6909.2008.00227.x
Accepted October 2007

V
iolence weapons ... extinguish begins long lives. before Where fists resentment fly or lethal and aggression routinely displace cooperation
and commu- nication, violence has occurred.
— Bernice Fields, Arbitrator (Namie, 2003).
Incivility, bullying, and subsequent shame responses are formidable forces that threaten the well-being of both nurses and patients. This
article provides a description of the disruptive behaviors associated with incivility and bullying and their subsequent adverse clinical
outcomes. A description of incivility and bullying in the workplace is followed by a discussion of nurses ’ risk for shame responses to these
negative behaviors. Implications for nursing practice are presented and nursing interventions proposed.
Keywords ​incivility bullying

Prevalence and Effects of Disruptive Behaviors ​disruptive behaviors shame ​in the Workplace ​violence
workplace violence harassment
Since the 1990s, recognition of negative workplace behaviors has increased (Lutgen-Sandvik, Tracy, & Alberts, 2007). These disruptive
behaviors include use of verbally abusive language, intimidation tactics, sex- ual comments, racial slurs, and ethnic jokes. Additional
disruptive behaviors include shaming or criticizing team members in front of others; threatening team members with retribution, litigation,
violence, or job loss; throwing instruments, and hurling charts or other objects ( Pfifferling, 2003; Porto & Lauve, 2006 ). In a
poll by U.S. News and World Report, 89% of Ameri- ​Correspondence
cans identified incivility as a serious social problem ​Dianne M. Felblinger, EdD, MSN, WHNP-C, CNS, RN, College of Nursing, University
and 78% agreed that it had worsened in the past 10 years ( Marks, 1996 ). Incivility continues to invade the
of Cincinnati, P.O. Box
workplace regardless of setting ( Hutton, 2006 ), and ​210038, Cincinnati,
the psychological harassment of nurses at work is an ​OH 45221-0038. dianne.felblinger@uc.edu
ongoing concern.

EdD, MSN, WHNP-C, CNS, RN,

1​
​ associate professor,
Incivility and bullying flourish in unsupportive work groups that normalize competitive and abusive behav- ​women ’ s health nurse
iors. Nurses work in groups; they negotiate complex in- ​practitioner, College of Nursing, University of Cincinnati, OH
terpersonal relationships in highly politicized settings with economic restrictions. As the nursing shortage per- sists, nurses take on increasing
responsibility and are ​Dr. Felblinger reports receiving
expected to provide leadership in situations that are of- ​consulting fees from Procter and Gamble, Inc. She disclosed no other potential con​fl ​icts of
ten unpredictable and chaotic. Under these circum- stances, many nurses encounter verbal abuse when
interest relevant to this article.
coworkers ineffectively cope with difficult work-related challenges by lashing out at each other ( Taylor, 2003 ). In some situations, nurses
engage in destructive nurse- to-nurse or “ horizontal ” hostility, through actions such as critical commentary, career sabotage, and gossip (
Thomas, 2003 ).
Prevalence of Abusive Behavior ​Previous research indicates that coworker incivility and bullying are more prevalent than blatant and
overt types of violence such as battery or homicide ( Baron & Neuman, 1996, 1998 ). Verbal abuse is described as a common experience
among health care providers, with a prevalence of 80% to 90% ( Sofield & Salmond, 2003 ). Bullying prevalence rates have been reported
between 1% and 4% ( Einarsen, 2000 ).

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Most verbal abuse in cases involving nurses is insti- gated by physicians; yet, nurse-instigated instances of verbal abuse are the second
most common type ( Johnson, DeMass, & Marker-Elder, 2007 ). In 2004,
More than half of nurses surveyed by Joint Commission on ​
Accreditation of Healthcare Organizations reported
that they had been subject to verbal abuse.
more than half of nurses surveyed by the Joint Commis- sion on Accreditation of Healthcare Organizations (JCAHO) reported that they had
been subject to verbal
intent to harm the target, in violation of workplace norms
abuse, and more than 90% had witnessed disruptive
for mutual respect. ” Pearson, Andersson, and Wegner
behavior (JCAHO, 2002). In a 2005 hospital survey,
(2001) further characterized workplace incivility as in-
72% of nurse respondents reported witnessing disrup-
clusive of “ rude and discourteous behavior, displaying
tive behavior perpetrated by another nurse ( Rosenstein
a lack of regard for others. ”
& O ’ Daniel, 2005 ). This survey defined disruptive be- havior as any inappropriate behavior, confrontation, or conflict ranging from verbal
abuse to physical and sex- ual harassment.
Incivility includes both subtle and obvious levels of rude and discourteous behavior, exclusion from impor- tant work activities, taking credit
for another ’ s work, withholding important information, yelling, screaming,
In a recent study, intimidating behavior demonstrated
verbal attacks, and expression of negative verbal com-
by professionals in labor and delivery units included an-
ments in front of others. During life-threatening situa-
gry outbursts; rudeness; verbal attacks; physical threats
tions, women ’ s health nurses and physicians may
or aggressive physical contact; violation of policies;
verbally criticize or blame team members for unfavor-
sexual harassment; idiosyncratic, inconsistent, or pas-
able outcomes. Other common examples of incivility
sive aggressive orders; derogatory comments about
include berating colleagues or workers in e-mail com-
the organization; and disruption of smooth function of
munications; exhibiting emotional tirades, angry out-
the health care team ( Veltman, 2007 ). Although physi-
bursts, or overt temper tantrums; interrupting others;
cians displayed the largest incidence of disruptive be-
and disrupting meetings. Individuals may be self-
havior (in 69.1% of cases) nurses’ behavior was
serving and unable to empathize, constantly negative,
disruptive in the remaining 30.9%.
condescending, and refusing to work collaboratively with administrators or peers. Gossiping and spreading ​Risks to Patients
rumors that damage a coworker ’ s reputation, name-
When incivility and bullying are sustained through dis-
calling, and discounting input from others at any
ruptive behaviors in the workplace, nurses suffer and
organizational level also contribute to a hostile work
patient care is adversely affected. Twenty-five percent
environment ( Table 1 ).
of health care workers saw a strong link between dis- ruptive behaviors and patient mortality, and as many as 53% and 75% of health care
providers saw a strong link between disruptive behavior and adverse clinical out- comes, such as patient safety, errors, adverse events,
quality of care, and patient satisfaction ( Rosenstein & O ’ Daniel, 2005 ). In a study by the Institute for Safe Med- ication Practices ( ISMP,
2004 ), 49% or almost half of all respondents stated that intimidation interfered with the way they clarified medication orders or dispensed a
Keashly (2001) further postulated that the most fre- quent form of workplace aggression is emotional and psychological in nature and stated
that behaviors be- come increasingly improper when they are repetitive, result in harm or injury, and are experienced as a lack of recognition
of the individual ’ s integrity. Keashly ’ s fo- cus on the meaning of the behaviors for the target pro- vides an enriched perspective of the
definition of incivility.
product or led them to administer a medication despite concerns. ​Incivility as a Precursor of Bullying

Although incivility is considered professional miscon- ​

Incivility
duct, a breech of etiquette, and representative of moral decay, the question of intent to harm distinguishes inci- ​Characteristics of
Incivility
vility from bullying or other forms of aggressive behav- In order to eradicate incivility and bullying behaviors,
ior. Namie (2003b) considered incivility a type of nurses and administrators must first understand fully
organizational disruption and rated it at a level of 1 to 3 what they are. The literature provides various definitions
on a 10-point continuum, with bullying rated as 4 to 9 of incivility. In general, incivility is seen as a form of
and battery or homicide rated as a 10. Incivility has psychological harassment and emotional aggression
been seen as a precursor to harassment, aggression, that violate the ideal workplace norm of mutual respect.
and physical assault ( MacKinnon, 1994 ). However, the Andersson and Pearson (1999) defined workplace inci-
relationship of incivility to bullying remains under vility as “ low-intensity deviant behavior with ambiguous investigation. ​JOGNN 2008; Vol. 37,
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Bullying
Characteristics of Bullying ​Workplace bullying is a form of aggression at work ( Neuman & Baron, 2005 ) that goes beyond incivility.
Bullying is a more deliberate and repetitive form of inter- personal behavior that adversely affects the health or the financial well-being of the
targeted person. Work- place bullying consists of recurrent and persistent neg- ative actions toward one or more individual(s), which involve
a perceived power imbalance and create a hos- tile work environment ( Salin, 2003 ). Bullying is a form of interpersonal mistreatment that
escalates the intensity of verbal assault, directs attention and energy away from the job, and may subsequently render the targeted nurse at
risk for unsafe clinical performance (ISMP, 2004). Intimidating workplace behavior can include threats to professional status, threats to
personal stand- ing, isolation, overwork, and destabilization ( Rayner & Hoel, 1997 ).
Bullying is persistent and has detrimental or negative effects on the victim ( Cusak, 2000; Quine, 1999; Randall, 1997 ). Bullying, or “
mobbing ” as it is called in many Continental European countries, is defined by Namie (2003) as a “ status-blind interpersonal hostility that is
deliberate, repeated and sufficiently severe as to harm the targeted person ’ s health or economic status. ” Randall described bullying as “
the aggressive behavior arising from the deliberate intent to cause physical or psychological harm. ”
Power and Control Are Key to Bullying ​Both stress theory and conflict theory provide a context in which to understand bullying. In
the context of stress theory, bullying is perceived as a severe form of social stress at work. In conflict theory, bullying signifies an unsolved
social conflict that has reached a particularly high level of escalation with an increased imbalance of power ( Zapf & Gross, 2001 ). An
example of this type of “ power-over ” situation occurs when hospital administra- tors continually expect obstetric, gynecologic, and neo-
Table 1 : Common Examples of Workplace Incivility
natal nurses to provide safe care with inadequate and unsafe levels of staffing. ​Exclusion from important work activities Yelling, screaming, verbal
attacks
Taking credit for another ’ s work Emotional tirades, angry outbursts
Einarsen (2000) identified predatory bullying as the abuse of power over another individual. Zapf and Gross ​Refusing to work collaboratively
Overt temper tantrums
(2001) , building on work from Einarsen, Einarsen and ​Interrupting others Gossiping
Skogstad (1996) , and Leymann (1996) , strictly defined ​Disrupting meetings Name-calling
bullying as occurring when someone is “ harassed, of-
Discounting input from others Condescending speech, rudeness
fended, socially excluded, or has to carry out humiliat-
Berating workers on e-mail Spreading rumors
ing tasks and if the person concerned is in an inferior
Failing to share credit for collaborative work Inability to empathize
position. ” To consider a behavior as bullying, it must oc- cur repeatedly (at least twice a week or more) and for a ​Withholding important
information Damaging coworker ’ s reputation
long time (at least 6 months or more) in situations where targets find it difficult to defend against and stop the abuse (Lutgen-Sandvik et al.,
2006). A single event is not bullying, nor is an event categorized as bullying if two equally strong parties are in conflict (Zapf & Gross).
Bullying, more than incivility, involves systematic ha- rassment for a long period of time and the instigator ’ s desire to control the target. This
obsession with control drives the instigator ’ s actions and invokes psychologi- cal pain on the part of the target. Targets of workplace bullying
endure their pain for an average of 22 months if they are unwilling or unable to react assertively to un- wanted aggression (Namie, 2003).
Bullying, similar to intimate partner violence, escalates when the target fi- nally decides to assert independence, moves ahead in the
corporate environment, or begins to set limits on the instigator ’ s behavior. As the target becomes more inde- pendent, the instigator asserts
more control. With in- creased instigator exertion of “ power over, ” the target diverts emotional energy away from work-related re-
sponsibilities and focuses this energy on coping with the situation. As the target is victimized by continued bullying and controlling behaviors,
self-blame develops. Internalization of this blame, self-reproach, and self- recrimination enables revictimization of the target. While the target
is preoccupied with self-blame, the instiga- tor ’ s behaviors go unimpeded. Rude and discourteous behaviors are often ignored or minimized
by manage- ment despite the repetitive and aggressive nature of the offense. These recurring sublethal behaviors may render the targeted
nurse professionally unsafe (ISMP, 2004).
Effects of Bullying on the Target ​Bullying causes serious health problems in the target of the bullying ( Einarsen, 2000 ). Many
targets of bullying suffer from post-traumatic stress disorder and symp- toms of low self-esteem, anxiety, sleep disturbance, re- current
nightmares, somatic problems, concentration difficulties, irritability, depression, and feelings of self- hatred ( Mikkelsen & Einarsen, 2002 ).
Some targets feel that their health is permanently impaired and
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they will never function normally or resume work again
dren learn to develop increasing independence in a ( Leymann, 1996 ). Bullying results in the loss of bright,
supportive, nonshaming atmosphere, and this need for talented, and motivated women ’ s health and neonatal
supportive relationships continues throughout adult life. nurses. Since mistreatment of nurses in the workplace
It follows that adult nurses would also thrive in an envi- may result in adverse clinical and personal outcomes,
ronment where they are not constantly criticized, where there is a need to develop a deeper understanding of
incivility and bullying are not tolerated, and where sham- the nurses ’ reaction to nonphysical types of violence
ing is not a norm of behavior. such as incivility and bullying. The link between incivil- ity, bullying, and shame is worthy of discussion and fur-
ther investigation.
Kohut (1971) also discussed the concept of evolution of the self. Kohut saw the condition of self developing more positively and “ unfolding in

an affirming environ- ment. ” The work of both Erikson and Kohut emphasizes ​Shame
the importance of development in a supportive environ-
Psychological effects of bullying may include a shame response that results in an “ attack-self ” phenomenon.
ment with norms that do not tolerate a hostile environ- ment of incivility and bullying.
When nurses are first victimized by emotionally abu-
Kaufman (1996) described shame as “ an affective sive behaviors, their immediate response may be one
experience that violates both interpersonal trust and in- of shame and anger. The nurses ’ initial shame re-
ternal security. ” Kaufman believed that everyone expe- sponse to violence can elicit an attack-self coping re-
riences self-doubt, looks internally to find the source of action that is characterized by inner-directed anger
discomfort, and blames the self for any inadequacies. ( Nathanson, 1992 ). When nurses attack themselves
This self-blame leads to insecurities about one ’ s iden- and direct their anger inward, they once again
tity. “ Where we once stood secure in our personhood, become victimized, which is known as revictimization
now we feel a mounting inner anguish, a sickness of the ( Figure 1 ). Concurrent with eradication of incivility
soul ” ( Kaufman, 1985 ). When nurses become targets of and bullying, nurses may also benefit from learning
incivility or bullying, look internally, blame themselves to manage their own shame response to these nega-
for the situation, and mobilize an attack-self coping tive behaviors. Eliminating the shame response may
mode, shame may be imminent. facilitate the avoidance of revictimization and leave nurses free to invest more psychological energy in
Effects of Shame Responses ​safe patient care.
In situations where incivility or bullying, or both occur,
To grasp the magnitude of the shaming process and its proposed relationship to coworker violence, it is helpful to first understand that
everyone experiences shame. The phenomenon of shame has been documented in the literature since the late 1800s. Freud wrote that
shame is an affective response to exposure and a com- ponent of intrapsychic conflict. Freud (1892-1899) be- lieved that people “ keep back
part of them they ought to tell — things that are perfectly well known to them — be- cause they have not got over their feeling of timidity and
shame. ” This historic perspective is certainly congruent with the behavior of the bully ’ s target, who “ keeps back ” and endures the pain for
an average of almost 2 years (Namie, 2003).
the targeted nurse may not recognize or be able to la- bel the subtle or overt aggression and shaming experi- ence. The nurse consequently
develops a self-blaming attitude, silently endures the situation, and may sub- sequently exhibit unsafe clinical behaviors in an intimi- dating
work environment (ISMP, 2004). Mounting shame in this negative situation often leads to anger ( Pastor, 1995 ). As the nurse experiences
difficulty discharging this anger appropriately, there is a propen- sity for emotional self-blame in conjunction with an in- ternalized, attack-self
mode of coping. According to Lewis (1971) , the experience of shame is a direct pre- cursor to a negative self-evaluation on the part of the
target. ​Tomkins (1963) , an experimental psychologist, pub- Shame
​ Impairs Development
lished much of the seminal work about Affect Theory ​of a Healthy Self
and shame. Tomkins viewed shame as an affect with In the 1960s, Erikson investigated shame from a devel-
“ relatively high toxicity ” that leaves a person emotionally opmental perspective. Erikson proposed eight psycho-
“ defeated, alienated and lacking in dignity. ” Tomkins social stages during the human life span. Autonomy
believed that shame occurs when the positive affects of versus Shame and Doubt is the second stage and oc-
excitement and enjoyment are blocked and reduced. curs initially at ages 1 to 3 of life. During this stage, chil-
For example, incivility and bullying behaviors in the dren who are consistently criticized for expressions of
nursing workplace may act as impediments to feelings autonomy or for lack of control develop a sense of
of interest-excitement or enjoyment-joy and invoke a shame about themselves and doubt their abilities. Chil-
shame response in the individual. When nurses are the
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When nurses are the targets of abusive behaviors, their work-related interest and enjoyment dissipate and their
safe clinical performance may suffer.
targets of abusive behaviors, their work-related interest and enjoyment dissipate and their safe clinical perfor- mance may suffer. For women
’ s health and neonatal nurses who take pride in their professional competence, this adverse situation may result in overwhelming shame.
Nathanson (1992) built on Tomkins work and described the shame affect as “ a highly painful mechanism that operates to pull the organism
away from whatever might interest it and make it content. Shame is painful in direct proportion to the degree of positive affect it limits ” (p.
138). This painful experience leads to decreased contentment and increased shame. In the work environ- ment, “ shame is by far the more
commanding affective experience in the life of mature, successful people. It is the fall from grace, the loss of face, the forfeiture of social
position accompanying exposure, that we fear most ” (p. 144).
Nurses ’ Responses to Shaming ​When shame is triggered, individuals respond in one of four defensive patterns: withdrawal,
avoidance, attack-others, and attack-self ( Nathanson, 1992 ). Withdrawal into the self provides respite from the shame experience and is
considered a healthy re- sponse because it provides safety from any further shame that might occur in the presence of others (Nathanson).
An avoidance reaction to shame occurs when no portion of the shame experience is emotion- ally tolerable to the target. Avoidance involves
the
self-deceptive patterns of ignoring, disavowing, or distracting oneself from the painful situation. The defensive pattern of attack-others
involves put-down, ridicule, contempt, and character assassination. The targeted nurse may outwardly direct this defensive behavior toward
nurse peers or patients. A targeted nurse who exhibits this attack-others response is at risk for the adverse consequences of conflict escala-
tion, one of which is further bullying or actual physical violence. Becoming a bully creates even more dan- gerous terrain (Nathanson).
For nurses who move into an attack-self mode, the self-mantra seems to be “ do unto yourself what you fear others may do to you ” (
Nathanson, 1992, p. 329 ). Prob- lems occur when the process of attacking the self feels better than having someone else do it. Those who
feel helpless in the face of bullying and incivility are most likely to use attack-self scripts to modulate shame. This attack-self tactic associated
with inner-directed anger is a revictimization of the nurse.
Interventions are needed to prevent the initial incivility and bullying behaviors that precede unsafe care and also activate an ensuing cascade
of shame and anger, leading to destructive, attack-self behaviors in the nursing workplace. When nurses realize that they are experiencing
shame as a result of work place abuse, they are in a prime position to obtain assistance to stop the abuse, avoid shame and revictimization,
learn new coping skills, prevent unsafe clinical behaviors, and confidently confront similar malicious situations.

Nursing Implications
Interventions for incivility and bullying behaviors are needed at both individual and administrative levels. Depending on the nurse ’ s
background and tempera- ment, the parameters of acceptable, respectful behav- ior may require definition. Some nurses are unfortunately
accustomed to tolerating behaviors that are outside the
Incivility and bullying victimization
realm of considerate conduct and are unaware that they are doing so. Education is needed at the individual and the unit level in an effort to
raise the awareness of everyone involved. Once the boundaries of ap propriate
Hostile workplace
Shame
interpersonal behaviors are identified and internalized, nurses and administrators can begin the serious busi- ness of creating a respectful
work environment.
The American Association of Critical Care Nurses
Anger Revictimization
Self-blame
(AACN) has developed a powerful position statement that supports zero tolerance for abuse. This statement
Self-attack
addresses the issue of intimidation and verbal abuse by peers, colleagues, and coworkers as a barrier to the provision of safe, quality care (
AACN, 2004 ). To encour-
Figure 1 . ​Victimization and revictimization in workplace violence.
age a culture of safety and excellence, the AACN has also published six essential, evidence-based, and
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relationship-centered standards for establishing and sustaining healthy work environments ( Table 2 ). In this document, AACN calls for the
development of commu- nication skills equal to the desired level of clinical prac-
Once the boundaries of appropriate interpersonal behaviors are identified and internalized, nurses and
administrators can begin to create a respectful work environment.
tice skills ( AACN, 2005 ). As communication skills increase, the level of incivility and bullying in the work- place may decrease.
research needs to draw on appropriate theoretical
Efforts such as the AACN Standards and Zero Toler- ance statement help eliminate incivility, bullying, and the associated disruptive
behaviors. The goal is the de- velopment of an emotionally safe work environment that
frameworks, address the contexts in which incivility or bullying occurs, and employ strong evaluation research designs, including attention to
process and outcome measures ( Runyan, Zakocs, & Zwerling, 2001 ).
empowers nurses and ultimately fosters the well-being
Interventions that create a positive organizational envi- of their patients. Implementation of AACN standards
ronment, retain nurses, and decrease interpersonal and a zero tolerance of abuse policy are two concrete
mistreatment are essential. When administrators inten- steps institutions can take to create and sustain a
tionally or inadvertently ignore the adverse effects of in- healthy work environment.
civility and bullying, employees respond with increased
Porto stresses the need for strong policy statements and a strong code of conduct, in addition to clear re- porting mechanisms and instant
access to senior lead- ers who are empowered to take immediate action ( Joint Commission Resources, 2006 ). Establishment of an
emotionally safe workplace benefits both nurses and
absenteeism ( Barling & Phillips, 1993 ), increased turn- over ( Rosenstein & O ’ Daniel, 2005 ), and heightened turnover intentions (
Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005 ). Reduced commitment to the organization also occurs (Barling & Phillips; Leather,
Beale, Lawrence, & Dickson, 1997 ).
their patients.
As employees react to interpersonal mistreatment with a
Although empirical evidence has linked a range of un- just, harassing, verbally abusive, or psychologically ag- gressive workplace behaviors
with adverse job-related consequences in individual targets ( Cortina, Magley, Williams, & Langhout, 2001 ), little organizational re- search
has tested interventions to reduce coworker mis- treatment in the forms of incivility and bullying. The presence of these behaviors affects the
organizational climate, and the negative effects multiply if left un- checked. Often the target is silenced and the instigator
shame response and gravitate toward an attack-self mode of coping, they begin to distrust and resent the unresponsive organizational
hierarchy. Administrative indifference and insensitivity to negative nuances, in turn, stifle employee participation, innovation, and cre- ativity (
Pearson et al., 2001 ). In a world where business survival is based upon efficiency, productivity, and in- novation, it is increasingly clear that
the development of a safe workplace, devoid of interpersonal mistreatment, is both desirable and necessary.
of the mistreatment avoids detection. Interventions need to be focused on altering the rewards and sanctions

Conclusions ​that instigators experience as part of the workplace cul- ture (Namie, 2003a).
Fostering a workplace in which nurses feel safe from intimidation directs valuable human energy toward at-
The lack of intervention research to assess administra-
tainment of organizational goals and contributes to in-
tive and behavioral measures and address interpersonal
creased productivity. Insights into the relationship
mistreatment represents a significant gap. Intervention
between incivility, bullying, and shame can help nurses
Table 2 : AACN Standards for Establishing and Sustaining Healthy Work Environments
Topic Standard
Skilled communication Nurses must be as efficient in communication skills as they are in clinical skills
True collaboration Nurses must be relentless in pursuing and fostering true collaboration
Effective decision making Nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading
organizational operations
Appropriate staffing Staffing must ensure the effective match between patient needs and nurse competencies
Meaningful recognition Nurses must be recognized and recognize others for the value each brings to the work of the organization
Authentic leadership Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage
others in its achievement
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understand the traditional nursing work environment from a different perspective. Development of interven- tions to facilitate a positive work
environment will require application of new and exciting paradigms, as well as thoughtful exploration and recreation of the conven- tional
work environment.
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Zapf , D. , & Gross , C . ( 2001 ). Conflict escalation and coping with
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behaviors and a. job satisfaction b. patient mortality
Continuing Nursing Education (CNE) Credit
c. patient safety 7. In a study by the Institute of Safe Medication
To take the test and complete the evaluation, please visit http://JournalsCNE.awhonn.org.
Practices almost half of respondents reported that intimidation
Certificates of completion will be issued on
a. led them to administer a medicine despite ​receipt of the completed evaluation form,
concerns ​application and processing fees. Note: AWHONN
b. rarely occurred on their own clinical unit ​contact hour credit does not imply approval or endorsement of any product or program.
c. stimulated nurse cohesiveness and
collaboration
Objectives
8. Bullying is present when health care providers
After reading this article the learner will be able
a. direct occasional negative behavior toward ​to: ​equally strong co-workers ​1. Identify disruptive behaviors associated with
b. systematically and repeatedly harass and at- ​incivility and bullying.
tempt to control co-workers ​2. Describe adverse outcomes of disruptive behaviors associated with incivility and bullying. 3. Identify standards
that help to create and
c. take credit for the work of others during an
annual evaluation 9. Nurses who are the targets of bullying behaviors
sustain a healthy work environment.
may develop
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Incivility, ​I ​N ​F ​OCUS
Bullying, and Shame Responses ​ CNE
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a. increased focus on safe patient care b. obsessive-compulsive behavior c. post traumatic stress disorder 10. Nurses who are targets of
bullying behaviors
may endure the pain for an average of almost a. 6 months b. 1 year c. 2 years 11. Nurses who experience a shame response to
bullying have an initial tendency to a. blame others for the situation b. blame themselves for the situation c. talk to administrators about the
bullying and
subsequent shame 12. The healthiest defensive responsive response to
shame is a. attacking others b. avoidance c. withdrawal 13. To achieve a respectful work environment, one of the first steps for nurses and
administrators is to
a. define appropriate interpersonal boundaries b. develop techniques for counter-attacking
abusers. c. learn how to ignore persistent bullying 14. AACN Standards for Establishing and Sustain-
ing Healthy Work Environments state a. nurses must be as efficient in communication
skills as they are in clinical skills b. nurses must be rated by the value each
brings to the work organization c. nurses must recognize that some abuse is an acceptable outcome of interdisciplinary collaboration 15.
Development of an emotionally safe work envi-
ronment that empowers nurses requires a. delineation of specific abusive behaviors that
are acceptable under stress b. implementation of a zero tolerance of abuse
policy c. further research to determine if abusive be- haviors foster job-related consequences in individuals.
242 ​JOGNN, 37, 234-242; 2008​. DOI: 10.1111/j.1552-6909.2008.00227.x http://jognn.awhonn.org