Draft American Nurses Association Position Statement: Incivility, Bullying, and Workplace Violence SEEKING PUBLIC COMMENT © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. Guidance for Public Comment The Workplace Violence and Incivility Professional Issues Panel is seeking public comment on the draft position statement titled “Incivility, Bullying, and Workplace Violence.” The attached document is a draft version of the anticipated position statement and contains a summary of ANA’s position on the issue. The final document is expected to be available this August. Download draft document (see below) and submit comments referencing line numbers. Comments must be received by 5pm ET on Thursday, April 30th. This document is for public comment purposes only and should not be quoted or referenced. For questions or technical issues, please email [email protected] ANA appreciates your time and review of this important document. © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 1 2 3 4 5 6 7 8 I. Purpose: This statement articulates the ANA position with regard to joint roles and responsibilities of registered nurses and employers to create and sustain a culture free of incivility, bullying and workplace violence. Registered nurses and employers across the professional continuum in all settings have an ethical and legal responsibility to create a healthy work environment for nurses and all members of the health care team, patients, families and communities. 9 10 11 12 13 14 15 II. Statement of ANA Position: 16 17 18 19 20 All registered nurses and employers in all settings, including practice and academia, must collaborate to create a culture free of incivility, bullying, and workplace violence. Best practice strategies based on evidence must be implemented to prevent and mitigate incivility, bullying and workplace violence; to promote the health, safety, and wellness of registered nurses; and to ensure optimal outcomes. 21 22 23 24 25 This document, although written specifically for registered nurses and employers, is also relevant to other health care providers and stakeholders who collaborate to create and sustain a safe and healthy interprofessional work environment. Stakeholders who have a contractual relationship with the worksite have a responsibility to address incivility, bullying and workplace violence. 26 27 28 29 30 31 32 33 34 35 36 37 38 39 III. Background The Code of Ethics clearly states that nurses are required to “create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect.” Similarly, nurses must be afforded the same level of respect and dignity as others (ANA, 2015). Thus, the nursing profession will no longer tolerate violence of any kind. Incivility, bullying and violence are part of a larger complex phenomenon, which includes a “constellation of harmful actions taken and those not taken” in the workplace (Saltzberg, 2011). Some actions may be more overt such as making demeaning comments or using intimidation to undermine a coworker; while other forms of incivility and bullying can be more covert such as failing to intervene or withholding vital information when actions are clearly indicated and needed for work to be done in a safe manner. These actions and actions not taken currently occur along a continuum and range from the subtle and covert, to overt, and from less to more harmful (Leymann, 1990; Andersson & Pearson, 1999, Namie 2003; Clark, 2013; Einarsen, Hoel, Zapf & Cooper, 2011; World Health Organization, 2015). Unfortunately, the full range of actions related to this complex phenomenon has impacted nurses globally, and in many cases has been accepted and culturally condoned. Left unimpeded for nearly a century, some © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 40 41 42 43 form of incivility, bullying, or violence touches far too many members of the nursing profession; it affects every nursing specialty, occurs in virtually every practice and academic setting, and extends into every educational and organizational level of the profession. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 To eliminate harmful actions and actions not taken in the workplace requires that its existence must first be acknowledged. Those who experience workplace incivility, bullying or violence know firsthand its harmful, detrimental effects; they bear the heaviest burden such intimate knowledge brings with it, especially when their experiences are not taken seriously by colleagues and institutional leaders. Any form of workplace violence puts the nursing profession and nursing’s contract with society in jeopardy (Saltzberg, 2011). Those who witness workplace violence and do not acknowledge it, choose to ignore it, or fail to report it (Hutchinson, 2009) are in fact perpetuating it, and “organizations that fail to address” it “through formal systems are indirectly promoting it” (Joint Commission, 2008). Refusal to engage in what has become accepted workplace norms surrounding workplace violence takes courage and is a moral stance consistent with the American Nurses Association Code of Ethics (2015). Such bold action taken by a small few is simply not enough to eliminate it. The entire nursing profession must unite in the effort to end violence in the workplace. 58 59 60 61 62 63 64 65 66 67 68 69 70 71 Nurses and their employers should acknowledge the various forms of workplace violence, and the extent that each occurs in their institutional setting. By differentiating these various forms of harmful actions and actions not taken, the entire profession can focus its collective wisdom and experience on leading the campaign to end it. For example, incivility can take the form of rude and discourteous actions, which are an affront to the dignity of a co-worker and violate professional standards of respect. These actions may include name calling, use of a condescending tone and public criticism (Andersson & Pearson, 1999; Read & Laschinger, 2013). The negative impact of incivility can be significant and far-reaching, affecting not only the target(s) themselves, but bystanders, peers, stakeholders, and organizations, and if left unaddressed, in some cases, may progress into threatening situations or violence (Clark, 2013). Often times, incivility is not directed at any specific person or persons; however it may perpetuate or become a pre-cursor to bullying and workplace violence, and therefore cannot be characterized as innocuous or inconsequential (Pearson et al., 2005). 72 73 74 75 76 77 Bullying is repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient (Sauer, 2012). Bullying actions include those that harm, undermine, and degrade; they include hostile remarks, verbal attacks, threats, taunts, intimidation, and the withholding of support (McNamara, 2012). Such actions occur with greater frequency and intensity than those described as incivility, represent serious safety and health issues, and can cause lasting physical and psychological difficulties © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 78 79 80 81 82 83 84 for recipients (Washington State Labor and Industries, n. d). Bullying often involves an abuse or misuse of power, creates feelings of defenselessness and injustice in the recipient, and undermines an individual’s inherent right to dignity. Bullying encompasses those harmful actions and actions not taken by supervisors against their subordinates, and employees against their peers, along with those actions taken and not taken by institutional leaders, which allow bullying to emerge and to become an accepted and condoned workplace norm. 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 In 1990, Leymann described workplace mobbing as an adult form of bullying displayed as employees “ganging up” on a target employee and subjecting him or her to psychological harassment that may result in severe psychological and occupational consequences for the victim. In some cases, targets of mobbing may be excellent and exceptional workers. For example, Westhues (2004) suggested that mobbing behaviors among faculty in academic workplaces may be related to the envy of excellence and jealousy associated with the achievements of others. This phenomenon may occur in an attempt to maintain group mediocrity and compliance with the established status quo; such that the high performer is targeted to keep him or her in line with prevailing cultural norms. Nurses and employers must also be cognizant of workplace mobbing, an extreme form of collective bullying or aggression aimed at ostracizing, marginalizing, or expelling an individual from a group (Harper, 2013). Simply stated, workplace mobbing is a type of bullying where more than one person commits egregious acts to control, harm and eliminate a targeted individual (Griffin & Clark, 2014). Mobbing causes physical, psychological, social and emotional damage, and can have devastating economic consequences as the target fights to keep their job and career. 101 102 103 104 105 106 107 Workplace violence consists of physically and psychologically damaging actions which occur in the workplace or while on duty (National Institute for Occupational Safety and Health [NIOSH], 2002). Workplace violence can lead to emotional distress, temporary or permanent injury or even death (Tarkan, 2008). Examples of workplace violence include direct physical assaults (with or without weapons), written or verbal threats, physical or verbal harassment, and homicide (Center for Disease Control [CDC], 2014; Occupational Safety and Health Administration [OSHA], n. d.). 108 The NIOSH classifies workplace violence into four basic types: 109 110 111 112 113 114 Type I involves “criminal intent”. In this type of workplace violence, “individuals with criminal intent have no relationship to the business or its employees”. Type II involves a customer, client or patient; in this type an “individual has a relationship with the business and becomes violent while receiving services”. Type III violence involves a “worker-on-worker” relationship and includes “employees who attack or threaten another employee”. © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. Type IV violence involves personal relationships. It includes “individuals who have interpersonal relationships with the intended victim but no relationship to the business”. 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 An overview of relevant literature indicates how prevalent incivility, bullying, and workplace violence has become in the nursing profession, healthcare field, and beyond (Spector, Zhou & Che, 2013). Kaplan, Mestel and Feldman (2010) suggest that nurses ignore or tolerate incivility and bullying, because of fear or lack of knowledge, however, incivility and bullying are reasons one in three nurses leave their job (Vessey, DeMarco & DeFazio, 2010). Research examining incivility, bullying and workplace violence has demonstrated the negative effects these have on individuals. One effect is a heightened level of psychological stress experienced by those exposed (Demir & Rodwell, 2012; Gates, Gillespie & Succop, 2011; Gillespie, Gates & Berry, 2013; Magnavita, 2014; Nicholson & Griffin, 2014; Stecker & Stecker, 2014; Wing et al., 2013). Some report that this heightened stress may advance to the level of posttraumatic stress disorder (Gillespie, Bresler, Gates & Succop, 2013) or depression (Gullander et al, 2014). Other negative effects include decreased job satisfaction, organizational commitment, and personal health (Rodwell, Brunetto, Demir, Shacklock & Farr-Wharton, 2014; Smith, Andrusyszyn & Spence Laschinger, 2010). 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 Incivility, bullying, and workplace violence also occurs in academic settings affecting students, faculty, and all members of the campus community. The dynamics of incivility are multidimensional, and may occur between faculty-student, student-student, studentfaculty, and faculty-faculty (including administrators). However, despite the dimension and direction of academic incivility, the effects of an uncivil encounter can be lasting and significant (Clark, 2013) and not only disrupts the learning environment, but is considered unprofessional and in violation of several foundational statements and positions. For example, Essential VIII: Professionalism and Professional Values described by the American Association of Colleges of Nursing (AACN, 2008) underscores the importance of nurses being accountable and responsible for their individual actions and ensuring that civility is present so that professionalism can occur. Similarly, Provision 1.5 of the American Nurses Association (ANA) Code of Ethics (2015) requires nurses to treat colleagues, students, and patients with dignity and respect and that any form of harassment, disrespect, or threatening action will not be tolerated. In addition, the Institute of Medicine (2010) report recommends empowering nurses to participate in collaborative efforts to improve work environments and health care systems. These foundational documents support the need for civility that must be continuously demonstrated by nurses in all areas of nursing education and practice. 152 © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 153 154 155 156 157 158 159 160 161 Most researchers assume there is face to face interaction with the perpetrator, although one study found incivility experienced through email had similar effects on individuals in the workplace (Guimetti et al, 2013). Decreased productivity can occur following incidences of incivility, bullying or workplace violence, and staff retention becomes more difficult, yet the financial cost is very difficult to calculate (Berry, Gillespie, Gates & Schafer, 2012; Chapman et al, 2010; D’Ambra & Andrews, 2014; Edward, Ousey, Warelow & Lui, 2014; Gates et al, 2011; Hegney et al, 2010; Laschinger, 2014). “Lost productivity as a result of [workplace incivility] was calculated at $11,581 per nurse per year” (Lewis & Malecha, 2011). 162 163 164 165 166 167 168 169 170 171 Another study in a US hospital employing 5000 nurses, estimated the cost of workplace violence treatment at $94,156 annually. This included $78,924 for treatment and $15,232 for indemnity for the 2.1 % of their nurses that reported injuries (Speroni, Fitch, Dawson, Dugan & Atherton, 2014). According to the Bureau of Labor Statistics, “13 percent of…non-fatal injuries and illnesses requiring days away from work in the health care …sector were the result of violence”; this “rate increased for the second year in a row to 16.2 cases per 10,000 full-time workers, up from 15.1 in 2012”, while the private sector rate was 4.2 cases per 10,000 full-time workers (U.S. Department of Labor, Bureau of Labor Statistics, 2014). 172 173 174 175 176 177 178 The establishment of positive respectful relationships is crucial to preventing incivility, bullying, and workplace violence. According to Provision 1 of the American Nurses Association Code of Ethics: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (ANA, 2015). Relationships marred by incivility and bullying can contribute to unhealthy work environments that ultimately impact the quality and safety of care delivered (AACN, 2005). 179 180 181 182 183 184 185 Respectful relationships in which each person is recognized and valued need to be fostered (AACN, 2005) in the workplace. Based on a study of registered nurses, Antoniazzi (2011) defines respect as “an open-minded willingness to accept, acknowledge, and value the uniqueness of an individual and her or his knowledge, experiences, and perceptions”. Respect is promoted through communication, collaboration, support, and fairness (Antoniazzi, 2011), each of which is foundational for nurses to establish healthy relationships with others. 186 187 188 189 IV. Responsibilities of Registered Nurses and Employers A safe work environment is one free of both physical and psychological harm. If members of the health care team do not feel safe, the work environment is left © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 190 191 vulnerable and everyone’s safety is compromised (National Patient Safety Foundation, 2013). 192 193 194 195 If incivility, bullying, and workplace violence exist as serious issues within the workplace, rebuilding trust within the workplace community is important. Staff and management must work together to identify specific issues and form a plan of action (Longo & Smith, 2011; Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005). 196 197 198 199 200 201 Effective interventions require ongoing employer commitment and genuine involvement of registered nurses (OSHA, 2004). A shared and sustained commitment to promote dignity and respect is necessary to preclude uncivil actions from escalating into threatening, bullying, and/or violence (Clark, 2013). The end goal is to promote and create a culture of health and safety that translates into a safe environment for nurses and other members of the health care team, patients, families, and communities. 202 V. INCIVILITY AND BULLYING: Recommended Interventions: 203 204 205 206 207 208 209 The following two sections detail recommendations for registered nurses and employers related to preventing and mitigating incivility, bullying, and workplace violence. Primary, secondary, and tertiary prevention strategies are included. Primary prevention involves measures to address vulnerabilities in order to prevent workplace violence. Primary prevention initiatives are also aimed at improving interpersonal relationships (ICN et al., 2005). Secondary intervention strategies are designed to reduce harm once an incident has begun and tertiary strategies reduce the consequences associated with the event. 210 211 212 A. Primary Prevention 213 Recommendations for Registered Nurses 214 215 216 217 218 219 220 221 222 223 224 225 1. Nurses must accept responsibility for establishing and maintaining healthy interpersonal relationships with one another and all members of the health care team (Manthey, 1988). 2. Nurses must be cognizant and aware of their interactions, behaviors, and communication with others to ensure that they do not engage in uncivil or bullying behavior. To facilitate this process, nurses should insist upon and participate in effective communication and conflict negotiation training offered by their employer. 3. Nurses should consider co-creating, implementing, and abiding by a team charter, commitment to co-workers, and/or ground rules that provide a foundation for fostering a civil workplace (Griffin & Clark, 2014) and must familiarize themselves with their employer’s incivility and bullying prevention © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 policies and procedures; and institutional codes of conduct (Clark 2014, The Joint Commission 2008). 4. Practice using predetermined phrases and responses developed to deflect and stop bullying prior to bullying is useful (Stagg et al, 2011). Utilizing cognitive rehearsal, nurses can be prepared to deflect uncivil or bullying when it occurs and equipped with an evidence-based strategy to address commonly occurring uncivil actions and inactions. (Griffin, 2004; Griffin & Clark, 2014). Posters and fliers with this information offer reinforcement after the training is given (Cleary et al., 2009). 5. Nurses individually and through their professional association should advocate for incivility and bullying identification and prevention education to be taught in schools of nursing. 6. Role model behaviors of respect and decorum to help reinforce civility and positive behavioral norms. Civility best practices include: a. Clear communication verbally, nonverbally, and in writing (including social media) b. Acknowledging others with respect and collegiality c. Thoughtfully considering personal words and actions’ impact on others d. Recognizing and respecting others e. Avoiding gossip and spreading rumors f. Relying on facts and not conjecture g. Collaborating and sharing information where appropriate h. Offering assistance when needed, if refused, accepting refusal gracefully i. Avoiding abusing one’s position or authority j. Taking personal responsibility/accountability for one’s own actions k. Speaking directly to the person with whom one has an issue l. Demonstrating an openness to other points of view m. Being polite and respectful and apologizing when indicated n. Refraining from uncivil, bullying, and disruptive behavior o. Encouraging, supporting, and mentoring others including new nurses p. Listening to others with interest and respect q. Being kind r. Above all, nurses, particularly nurse leaders must hold themselves to a higher standard and role model desired behaviors. (Becher & Visovsky, 2012) 264 265 266 1. Ensure that organizational foundational statements (i.e., vision, mission, philosophy, and shared values) are closely aligned with the concepts of civility and respect, and that the spirit and intent of these foundational statements Recommendations for Employers © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 2. 3. 4. 5. 6. 7. B. are shared and embraced by employees throughout the organization (Clark, 2013). Establish measurable professional behavior standards and enforce a zero tolerance policy. a. This zero tolerance policy begins with the top down, meaning upper management must be especially vigilant for bullying in their ranks and eliminate it immediately. b. Human Resources must also be active in enforcing the zero tolerance policy. c. Employees must be informed of and comfortable with well-established bullying reporting mechanisms. Clinical educators should be an integral part of the training offered as they understand the specific hospital system and its navigation (Longo, Dean, Norris, Wexner, & Kent, 2011). Formal education sessions defining bullying, identifying bullying behaviors, basic behavior modification, and detailing of consequences when bullying occurs are needed (Edwards & O’Connell, 2007). Academic and practice nurse leaders must collaborate to develop and implement a shared vision and mission for civility, integrating civility content throughout the nursing curriculum, fostering leadership at all levels (both formal and informal), and reinforcing and rewarding civility (Clark, Olender, Cardoni, & Kenski, 2011). Academic nurse leaders and nursing faculty play a key role in preparing nursing students to foster a civil, healthy workplace including providing ongoing civility education, integrating civility content throughout the curriculum, policy development and implementation for desired actions and behaviors, and providing stress reducing activities, coaching, and mentoring (Clark & Springer, 2010). Nursing curricula should include: professional communication, crisis management, effective conflict resolution (Luparell, 2011) and use of role play, clinical simulation, and problem-based scenarios to prepare nursing students to prevent and address incivility in academic and practice settings (Clark, Ahten, Macy 2012, 2014). Mentors or preceptors should be established for nursing students and new graduates. These mentors should role model professional behavior at all times, as well as guide and support their charges (King-Jones, 2011). Mentors must ensure they are comfortable with intervening and halting bullying. Bally refers to specific mentoring responsibilities that include counseling, teaching, protecting, coaching, and sponsorship (Bally, 2007). Secondary Prevention (Reduction of Impact) © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 309 Recommendations for Registered Nurses 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 1. Address incivility as soon as it is noted. When encountering incivility, the first time, as with bullying, confront the perpetrator and let them know firmly, but factually that the behavior is offensive and will not be tolerated. 2. Be assertive during the event by confronting the uncivil offender or bully and insist the bullying cease immediately. Remain calm and keeping the conversation factual by being specific about the behaviors of concern (Becher & Visovsky, 2012).The goal of this interaction is a return (or a start) to professional and collegial behaviors and relationships. (Cleary et al, 2009). 3. Once encountering incivility, nurses should rehearse what they will do if it happens again. This may include speaking directly to the person being uncivil about their incivility and if this is unsuccessful, referring the incident to a superior (Lambert et al, 2003). Using a TeamSTEPPS approach such as CUS or DESC models for respectful communication can be very effective (AHRQ, 2015). 4. Utilize existing codes to seek support during a bullying incident. For example, some facilities have established a “Code Pink” or “Code Incivility”. This involves a victim or bystander uttering “Code Pink” or similar phrase and all available nurses come stand by the victim to give nonverbal support and witness (Tillman Harris, 2011) 5. When witnessing a bullying event, interrupt the bully, support the victim, and ensure the victim reports the event. Be aware of the presence of patients and families when addressing the offender. 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 1. Enlist the support of leadership, use empirical measures to assess the type and level of incivility, and install a Civility Team to develop and implement an evidence-based civility-based Action Plan (Clark, 2013, 2014). 2. Spend time and resources to vet potential candidates for collegiality, teamwork potential, and desired interpersonal skills (Cipriano, 2011). 3. Employ stress management and reduction strategies 4. Consider techniques to enhance psychological hardiness (Lambert et al, 2003), self-care measures and self-reflection practices (Clark, 2014). 5. Consider adopting the model for conflict resolution suggested by AHRQ’s Team STEPPS program: describe the specific situation; express concerns; Suggest other alternatives; state consequences (AHRQ, 2013). Recommendation for Employers C. Tertiary Prevention (Reduction of Consequences) Documentation of Incidents 349 © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 350 351 352 353 354 355 356 1. Following the bullying event, report the event immediately through employers’ appropriate channels. This may include the human resources department, labor union, or a supervisor. 2. Keep a detailed written account of the incident(s) as it may develop into a pattern. 357 358 359 360 361 362 363 364 365 366 1. Obtain peer support or access similar support system, engage the employee assistance program, seek counseling, obtain legal counsel, and/or if your health is affected, consider filing a workers’ compensation claim (Longo, 2012; AANA NewsBulletin, 2007). 2. Provide support to colleagues who have been bullied. 3. Recognize one’s own uncivil behavior and apologize or make amends. Nurses can make an effort to stop certain behaviors if these contribute to uncivil interactions. 367 368 369 370 371 372 373 374 375 1. Designate a representative to meet with and intervene with both victim and perpetrator (Capitulo, 2009). 2. Consider establishing support groups and/or empowerment committees. These groups can also engage in research to identify other evidence-based solutions to intervene with bullying. 3. Monitor the perpetrator for a specific length of time, if necessary. 4. Transparency is key: all employees involved in the incident should know how it will be handled and how long the process will take (Cleary et al, 2009). 376 377 378 379 380 381 382 383 384 385 386 387 388 389 Recommendations for Registered Nurses - Following Incidents Recommendations for Employers - Following Incidents VI. WORKPLACE VIOLENCE: Recommended Interventions: A. Primary Prevention Recommendations for Registered Nurses 1. Actively participate in the development and implementation of the workplace violence prevention program. 2. Understand organizational policies and procedures related to workplace violence prevention and response. 3. Actively participate in education associated with the workplace violence prevention program. 4. Seek continuing education opportunities to learn more about violence prevention. 5. Understand the importance of using situational awareness to identify potential for violence before it occurs. For instance, question the presence of all visitors © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 6. 7. 8. 9. in patient rooms and not assume that someone is a family member or friend (The Joint Commission, 2010). Be aware of and know how to utilize environmental controls in your unit to prevent/reduce violent incidents. Continually incorporate personal health and wellness strategies in order to minimize stressors and detractors from patient care that could unintentionally contribute to aggressive outcomes. Provide and be open to receiving constructive, timely and respectful feedback from colleagues. Conduct and participate in research and quality improvement initiatives aimed at preventing, mitigating, and reporting workplace violence (Emergency Nurses Association, 2014). Recommendations for Employers 1. Create and support a culture of zero tolerance for all types of workplace violence. 2. Foster and maintain a supportive work environment where respectful communication is the norm and organizational policies are understood and followed (APNA, 2008). 3. Foster and maintain a “Just Culture” by encouraging reporting and never blaming staff for incidents and recognizing that staff should not be responsible for system failings over which they have no control (APNA, 2008; ANA, 2010). 4. Develop, implement, and sustain a comprehensive violence prevention program that is in alignment with OSHA’s “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers” (OSHA, 2004; Lipscomb & London, 2015). The program should be written, distributed to all staff, and updated regularly. Program elements include: a. Management Commitment and Employee Involvement: Employer commitment is the foundation of an effective workplace violence program. Genuine health care worker involvement is critical as health care workers are skilled at recognizing patients at risk for violence and identifying prevention strategies. i. Convene an interprofessional safety committee or workplace violence prevention committee, comprised of both employers and front-line health care workers, to plan and implement each phase of the prevention program. ii. Involve health care workers in each element of the violence prevention program. b. Worksite Analysis: A thorough analysis is necessary to identify trends and risk factors for violence. © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 i. Utilize all available data sources. Data sources may include OSHA logs, injury reports, workers’ compensation data, and staff surveys. ii. Conduct an analysis of each unit or department within an organization, paying special attention to those areas where incidents have occurred. Review and track incidents by organizational, environmental, patient, unit, and staff level factors. iii. Conduct regular walk throughs of all areas of the organization and include staff from every unit and every shift. iv. Repeat analysis periodically. c. Hazard Prevention and Control: Prevention and control measures are designed based on the result of the worksite analysis. i. Follow the hierarchy of controls: elimination, substitution, engineering controls, administrative controls, personal protective equipment (OSHA, 2015). ii. Engineering controls may include modifying the layout of admissions areas, nurses’ stations and rooms, ensuring adequate lighting, limiting access to certain areas, and securing or eliminating furniture or equipment that may be weaponized. iii. Administrative controls may include the development and implementation of policies and procedures, establishing codes (such as active shooter or disruptive patient codes), and conducting on-going training and education. iv. Personal protective equipment may include personal alarm devices, panic buttons, and cellular phone. d. Training and Education: Ongoing training and education for all staff is needed to ensure competency and communicate elements of the workplace violence prevention program. i. Training should be mandatory, conducted at the time of hire, and repeated frequently. ii. Include information on the prevalence of violence in health care and risk factors. iii. Provide an overview of related policies and procedures. Provide copies of the written workplace violence prevention program and detail reporting procedures. Communicate opportunities for staff to actively participate in the program. iv. Training should be specialized to the type of unit. For instance units with a documented incidence of violent acts, or at high risk for violence, such as emergency departments and psychiatric © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 units, may require more training on de-escalation techniques and use of restraints. v. Include mock drills of emergency scenarios, such as active shooter codes. vi. Incorporate de-escalation techniques, self-defense, and situational awareness into trainings. vii. Training/education should include a variety of methods including but not limited to hands on practice and simulation. e. Recordkeeping and Program Evaluation: Recordkeeping involves reporting of incidents and near-misses. The number and severity of incidents are tracked and used to evaluate and improve a violence prevention program. i. Staff should be mandated to report every incident of workplace violence and near misses without fear of retaliation from employers. ii. Communicate reporting procedures clearly and regularly to staff. iii. Conduct a comprehensive program evaluation annually to evaluate the impact of the workplace violence prevention. iv. Ensure adequate recordkeeping. 5. Work with the HR department to make sure it thoroughly prescreens job applicants, and establishes and follows procedures for conducting background checks of prospective employees and staff. a. Confirm that the HR department ensures that procedures for disciplining and firing employees minimize the chance of provoking a violent reaction. 6. Safe levels of staffing are essential to providing optimal patient care and ensuring a safer environment for patients and registered nurses (AACN, 2005; ANA, 2012). B. Secondary Prevention (Reduction of Impact) Recommendations for Registered Nurses 1. Understand and utilize existing administrative controls 2. Understand and utilize existing environmental controls (visitor access, panic buttons, et cetera). 3. Utilize crisis intervention skills to assess, plan, and intervene if the potential for workplace violence exists (Howard-Siewers, 2005). 4. Report concerns about weaknesses in the system in order to improve processes and communication. Utilize the approved reporting system. Recommendations for Employers © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 1. Continually identify strengths and weaknesses and make improvements to the workplace violence prevention program. 2. Treat all reports of suspicious behavior or threats seriously, and investigate thoroughly. 3. Train staff to recognize when an employee or patient may be experiencing behaviors related to domestic violence issues (The Joint Commission, 2010) 4. Provide access to technology, such as a panic button or personal safety devices that can be used to alert security, police, or designated organizational safety team to respond. 5. Develop an active shooter or hostage response plan (Phelps, Russell & Doering, 2007). 6. Review each reported episode of violence with a multidisciplinary team to identify ways to improve the system and mitigate future episodes of violence. C. Tertiary Prevention (Reduction of Consequences) Recommendations for Registered Nurses 1. Report all instances of workplace violence using established reporting procedures. 2. Participate in all related post-incident meetings. 3. Utilize counseling programs after an incidence of workplace violence. Recommendations for Employers 1. Ensure that procedures for responding to incidents of workplace violence (e.g., notifying department managers or security, activating codes) are in place and that employees receive instruction on these procedures. 2. Ensure that counseling programs for employees who become victims of workplace crime or violence are in place (The Joint Commission, 2010). VII. Summary of Relevant ANA Publications and Initiatives 545 2015 Publication: Code of Ethics for Nurses 546 547 548 549 550 551 The Code of Ethics for Nurses (the Code) makes explicit the primary goals, values, and obligations of the profession. ANA believes that the Code is nonnegotiable and that each nurse has an obligation to uphold and adhere to its ethical precepts. Four provisions within the Code speak to the obligation of registered nurses to act in a manner that is consistent with maintaining patient, co-worker and personal safety, civility, and/or respect: © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 This book serves as a resource to identify actions and best practices that nurses and their employers can employ to reduce workplace violence. Risk factors, worker rights, legal issues, worksite analysis, hazard prevention/control, training/education, and program evaluations are examined. The establishment of beneficial collaborations is emphasized. Case studies are also provided for further assistance. (Lipscomb et al, 2015). 582 Ongoing Initiative: HealthyNurse 583 584 585 586 587 588 The HealthyNurse™ initiative provides registered nurses with resources to guide them toward improved health, safety, and wellness. ANA defines a healthy nurse as one who actively focuses on creating and maintaining a balance and synergy of physical, intellectual, emotional, social, spiritual, personal, and professional wellbeing. Healthy nurses each live life to the fullest capacity, across the wellness and illness continuum, as they become stronger role models, advocates, and Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. Specifically, this provision reminds nurses that respect includes all individuals the nurse interacts with, including co-workers. Fair and kind treatment, best resolution of conflicts, and promoting a culture of civility is stressed. Bullying, harassment, violence, and other unacceptable behavior are not to be tolerated. Provision 3: The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. Provision 5: The nurse owes the same duties to self as to other, including the responsibility to health and safety, preservation of wholeness of character and integrity, maintenance of competence, and continuation of personal and professional growth. Provision 6: The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. Specifically, this provision addresses creation of a safe healthcare environment where nurses are supported in attaining and maintaining a higher moral code. This may be accomplished through a variety of practices including health and safety initiatives, policies addressing discrimination, and incivility position statements (ANA, 2015). 2015 Publication: Not Part of the Job: How to Take a Stand Against Violence in the Work Setting © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 589 590 educators, personally and professionally, for themselves, their families, communities, work environments, and ultimately for their patients (ANA, 2015). 591 2011 ANA’s Health & Safety Survey Report 592 593 594 595 This survey of over 4,600 registered nurses examined the unique health and safety risks registered nurses face in the workplace. Demographics and ANA membership were also surveyed. Participants reported that “an on-the-job assault” was in their top four most serious health and safety concerns (34%) (ANA, 2011). 596 2012 Publication: Bullying in the Workplace: Reversing a Culture 597 598 599 600 This booklet guides nurses in recognizing bullying, identifying its causes and consequences. It discusses the responsibilities of nurses, nurse managers, and employers in regard to bullying identification and mitigation. Actions to decrease bullying and how to respond to bullying are given (Longo, 2012). 601 2010 Publication: Scope and Standards of Practice Nursing 602 603 604 605 606 607 The Scope and Standards of Practice: Nursing (Scope and Standards) is the consummate resource on professional nursing practice. It examines the who, what, where, when, why, and how of nursing practice in measurable specific competencies that serve as evidence of compliance. Three standards within this document address the obligation of registered nurses to act in a manner that is consistent with maintaining patient, co-worker and personal safety, civility, and/or respect: 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 Standard 11 Communication: The registered nurse communicates effectively in a variety of formats in all areas of practice. Specifically, this standard asks that the registered nurse assesses her or his own communications skills with patients, families, and co-workers while improving personal communication and conflict resolution skills. Standard 12 Leadership: The registered nurse demonstrates leadership in the professional practice setting and the profession. Specifically, this standard requires the registered nurse to treat co-workers with respect, trust and dignity. Standard 13 Collaboration: The registered nurse collaborates with the healthcare consumer, family, and others in the conduct of nursing practice. Specifically, this standard asks the registered nurse to practice effective: conflict management/resolution, engagement, consensus building, and to adhere to codes of conduct and behaviors that foster cooperation, respect, and trust (ANA, 2010). A full list of ANA position statements can be found here. © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 626 627 628 629 630 631 VIII. References 632 633 634 American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from www.aacn.nche.edu/education-resources/baccessentials08.pdf 635 636 637 American Association of Critical-Care Nurses. (2005). AACN Standards for Establishing and Sustaining Healthy Work Environments. Aliso Viejo, CA: AACN. 638 639 640 641 642 643 644 645 American Association of Nurse Anesthetists. (2007). Workplace Incivility Part II: Managing the Dilemma. AANA NewsBulletin. 36-37. Accessed 3/5/15 from http://www.aana.com/resources2/healthwellness/Documents/nb_milestone_0407.pdf 646 647 648 American Nurses Association. (2015). HealthyNurse™. Retrieved from http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/HealthyNurs e 649 650 651 American Nurses Association. (2012). ANA's Principles for Nurse Staffing, Second Edition. Silver Spring, Maryland: Nursesbooks.org. 652 653 654 655 American Nurses Association. (2011). 2011 ANA Health & Safety Survey Report Backgrounder. Retrieved from http://nursingworld.org/FunctionalMenuCategories/MediaResources/MediaBackg rounders/The-Nurse-Work-Environment-2011-Health-Safety-Survey.pdf 656 657 American Nurses Association (2010). Position Statement: Just Culture. Retrieved from http://nursingworld.org/psjustculture. 658 659 American Nurses Association. (2010). Scope and Standards of Practice Nursing. Silver Spring, MD: Nursesbooks.org. Agency for Healthcare Research and Quality. (Revised 2013). Team STEPPSTM Pocket Guide-2.0. Publication #14-0001-2. Accessed 3/5/15 from http://www.ahrq.gov/professionals/education/curriculumtools/teamstepps/instructor/essentials/pocketguide.html American Nurses Association. (2015).Code of Ethics for Nurses with Interpretive Statements. Silver Spring, Maryland: Nursesbooks.org. 660 © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 661 662 663 American Psychiatric Nurses Association (2008). Workplace Violence: APNA Position Statement. Retrieved from http://www.apna.org/files/public/APNA_Workplace_Violence_Position_Paper.pdf 664 665 666 667 Andersson, L.M, Pearson, C.M. (1999). Tit for Tat? The Spiraling Effect of Incivility in the Workplace. Academy of Management Review. 24 (3) 452-471.doi 10.5465/AMR.1999.2202131 668 Antoniazzi, C.D. (2011). Respect as experienced by registered nurses. Western Journal 669 of Nursing Research, 33(6), 745-766. doi: 10.1177/0193945910376516 670 671 Bally, J.M. (2007). The role of nursing leadership in creating a mentoring culture in acute care environments. Nursing Economics, 25(3), 143-148. 672 673 674 675 676 Becher, J. & Visovsky (2012). Horizontal violence in nursing. Medsurg Nursing, 21(4), 210-232. Retrieved 3/5/15 from https://www.amsn.org/sites/default/files/documents/practice-resources/healthywork-environment/resources/MSNJ-Becher-Visovsky-21-04.pdf 677 678 679 680 Berry, P. A., Gillespie, G. L., Gates, D., & Schafer, J. (2012). Novice nurse productivity following workplace bullying. Journal of Nursing Scholarship, 44(1), 80-87. doi:10.1111/j.1547-5069.2011.01436.x 681 682 Capitulo, K.L. (2009). Addressing disruptive behavior by implementing a code of professionalism to transform hospital culture. Nurse Leader, 7(2), 38-43. 683 684 Centers for Disease Control and Prevention. (2014). Hierarchy of Controls. Retrieved from http://www.cdc.gov/niosh/topics/hierarchy/ 685 686 687 688 Chapman, R., Styles, I., Perry, L., & Combs, S. (2010). Examining the characteristics of workplace violence in one non-tertiary hospital. Journal of Clinical Nursing, 19(34), 479-488. doi:10.1111/j.1365-2702.2009.02952.x 689 690 Cipriano, R. (2011). Facilitating a Collegial Department in Higher Education: Strategies for Success. San Francisco, CA: Jossey-Bass. 691 Clark, C.M., Ahten, S.M., & Macy, R. (2014). Nursing graduates' ability to address 692 693 incivility: Kirkpatrick’s level-3 evaluation, Clinical Simulation in Nursing, 10(8), 425–431. © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 694 695 696 Clark, C. (2014). Seeking civility: The author offers strategies to create and sustain healthy workplaces. American Nurse Today, 9 (7), 18-21, 46. 697 698 Clark, C.M. (2013). Creating and sustaining civility in nursing education, Indianapolis, IN: Sigma Theta Tau International Publishing. 699 700 701 702 Clark, C. M., Ahten, S.M., & Macy, R. (2012). Using Problem Based Learning (PBL) scenarios to prepare nursing students to address incivility. Clinical Simulation in Nursing, 9(3), e75-e83. 703 704 705 Clark, C. M., Olender, L., Cardoni, C., & Kenski, D. (2011). 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Epub 2006 Jul 11. 726 727 728 Einarsen, S., Hoel, H., Zapf, D., & Cooper, C. L. (2011). Bullying and harassment in the workplace (2nd ed.). New York: CRC Press. Demir, D., & Rodwell, J. (2012). Psychosocial antecedents and consequences of workplace aggression for hospital nurses. Journal of Nursing Scholarship, 44(4), 376-384. Edward, K. L., Ousey, K., Warelow, P., & Lui, S. (2014). Nursing and aggression in the workplace: A systematic review. British Journal of Nursing (Mark Allen Publishing), 23(12), 653-4, 656-9. doi:10.12968/bjon.2014.23.12.653 © ANA. April 2015. FOR PUBLIC COMMENT PURPOSE ONLY. DO NOT CITE OR QUOTE. 729 730 731 732 Emergency Nurses Association. (2014). Violence in the Emergency Care Setting. Retrieved from http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Violencein theEmergencyCareSetting.pdf 733 734 735 736 Gates, D. M., Gillespie, G. L., & Succop, P. (2011). Violence against nurses and its impact on stress and productivity. Nursing Economic$, 29(2), 59-67. 737 738 739 740 741 742 743 744 Gillespie, G. L., Bresler, S., Gates, D. M., & Succop, P. (2013). Posttraumatic stress symptomatology among emergency department workers following workplace aggression. Workplace Health & Safety, 61(6), 247-254. doi:10.3928/2165079920130516-07 745 746 747 748 749 750 751 752 753 Giumetti, G. W., Hatfield, A. L., Scisco, J. L., Schroeder, A. N., Muth, E. R., & Kowalski, R. M. (2013). What a rude e-mail! examining the differential effects of incivility versus support on mood, energy, engagement, and performance in an online context. Journal of Occupational Health Psychology, 18(3), 297-309. doi:10.1037/a0032851 754 755 756 757 Gillespie, G. L., Gates, D. M., & Berry, P. (2013). Stressful incidents of physical violence against emergency nurses. Online Journal of Issues in Nursing, 18(1), 2-2. Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. 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Workplace violence: Differences in perceptions of nursing work between those exposed and those not exposed: A cross-sector analysis. International Journal of Nursing Practice, 16(2), 188-202. doi:10.1111/j.1440-172X.2010.01829.x 777 778 779 780 781 782 Hutchinson, M. (2009). Restorative approaches to workplace bullying: Educating nurses toward shared responsibility. Contemporary Nurse, 32 (1-2), 147-155. 783 784 785 786 787 788 International Labour Organization, International Council of Nurses, World Health Organization and Public Services International (2005). Framework guidelines for Addressing Workplace Violence in the Health Sector. Retrieved from: http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/--safework/documents/instructionalmaterial/wcms_108542.pdf 789 790 791 The Joint Commission (2010). Preventing violence in the health care setting. Sentinel Event Alert, 45, 1-3. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_45.PDF 792 793 794 The Joint Commission (2008). Behaviors that undermine a culture of safety. Sentinel Event Alert, 40 (July 29). Retrieved 3/3/15 from http://www.jointcommission.org/assets/1/18/SEA_40.pdf 795 796 797 Kaplan, K., Mestel, P., & Feldman, D.L. (2010). Creating a culture of mutual respect. AORN J, 91 (4), 495-510 798 799 King-Jones, M. (2011). Horizontal violence and the socialization of new nurses. Creative Nursing, 17(2), 80-86. 800 801 802 803 Lambert, V.A., Lambert, C.E. & Yamase, H. (2003). Psychological hardiness, workplace and related stress reduction strategies. Nursing and Health Sciences, 5(2), 181184. doi: 10.1046/j.1442-2018.2003.00150.x Retrieved from http://onlinelibrary.wiley.com/doi/10.1046/j.1442-2018.2003.00150.x/pdf 804 805 Laschinger, H. K. (2014). Impact of workplace mistreatment on patient safety risk and Howard-Siewers, M. (2005). Crisis intervention in the workplace. 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