Incivility, Bullying, and Workplace Violence

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 DO NOT CITE OR QUOTE.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.
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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.
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II. Statement of ANA Position:
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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.
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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.
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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
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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.
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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.
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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).
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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
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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.
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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.
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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.).
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The NIOSH classifies workplace violence into four basic types:
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 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”.
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 Type IV violence involves personal relationships. It includes “individuals who
have interpersonal relationships with the intended victim but no relationship to
the business”.
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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).
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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.
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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).
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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).
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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).
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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.
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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
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vulnerable and everyone’s safety is compromised (National Patient Safety Foundation,
2013).
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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).
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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.
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V. INCIVILITY AND BULLYING: Recommended Interventions:
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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.
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A.
Primary Prevention
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Recommendations for Registered Nurses
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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
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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)
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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
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2.
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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)
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Recommendations for Registered Nurses
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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.
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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
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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.
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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.
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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).
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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
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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.
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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
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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
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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
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2015 Publication: Code of Ethics for Nurses
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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:
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
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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).
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Ongoing Initiative: HealthyNurse
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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.
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educators, personally and professionally, for themselves, their families,
communities, work environments, and ultimately for their patients (ANA, 2015).
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2011 ANA’s Health & Safety Survey Report
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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).
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2012 Publication: Bullying in the Workplace: Reversing a Culture
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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).
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2010 Publication: Scope and Standards of Practice Nursing
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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:
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
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.
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VIII.
References
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