Defining Culturalism Assignment | Essay Help Services

Wk 3 Discussion – Defining Culturalism Respond to the following in a minimum of 175 words:    Nurse leaders must work with staff to foster respect for varied lifestyles. Showing respect to all patients and colleagues, irrespective of their cultural differences, tells staff that differences are valuable. This discussion is designed to introduce key principles that nurse leaders must address in leading and managing diverse groups.   Use Google Scholar™, Leading and Managing in Nursing, or the University Library to define multiculturalism, cross-culturalism, and transculturalism.   Explain the definitions in your own words and give an example of applying each term to a leadership situation. For example, think of a time in your practice when you, as a leader, or your leader used multiculturalism to promote inclusion among colleagues or patients.

Week 3 is designed to introduce students to some of the quality and risk issues that nurse leaders often face when defining and managing quality and risk


Wk 3 Discussion – Defining Culturalism


Respond to the following in a minimum of 175 words:


Nurse leaders must work with staff to foster respect for varied lifestyles. Showing respect to all patients and colleagues, irrespective of their cultural differences, tells staff that differences are valuable. This discussion is designed to introduce key principles that nurse leaders must address in leading and managing diverse groups.


Use Google Scholar™, Leading and Managing in Nursing, or the University Library to define multiculturalismcross-culturalism, and transculturalism.


Explain the definitions in your own words and give an example of applying each term to a leadership situation. For example, think of a time in your practice when you, as a leader, or your leader used multiculturalism to promote inclusion among colleagues or patients.


The Challenge

The Emergency Department Staff and Safety Manager*

University Medical Center at Brackenridge, Austin, Texas

University Medical Center Brackenridge (UMCB), a member of the Seton Healthcare Family, is a Level 1 trauma center located in a large urban area. We are near the heart of the downtown district and serve a broad cross section of the population. Our emergency department is busy all the time, and we never know what will come through the door. A nurse was assaulted by a patient with mental illness. After exhibiting threatening behavior, he was apprehended by the police and brought to our emergency department. He had been calm and compliant up until about 6 hours after admission. At that point he became aggressive and seriously injured the nurse. We needed to develop a safety policy.

    • What do you think you would do if you were a nurse on this team?

* Kevin Craven, MBA, BSN, RN, Director, Emergency Services; Kristina Walker, CSP, OHST Site Safety Officer


Workplace violence and incivility in health care have emerged as an important safety issue over the past decade. They are seen on a continuum from threats or intimidation to the most extreme form, homicide. Violence, whether from persons external or internal to an organization, has been shown to have negative effects, including increased job stress, reduced productive work time, decreased morale, increased staff turnover, and loss of trust in the organization and its management. By increasing personal awareness of workplace violence and incivility and by acquiring tactics for decreasing or preventing violence and incivility, nurses can contribute to better, safer healthcare organizations.

Defining Workplace Violence and Incivility

The Occupational Safety & Health Administration (OSHA) enforces safety standards and provides training and outreach to employers to ensure safe and healthful working conditions. OSHA (2013) defined workplace violence as any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the worksite. The definition includes overt and covert behaviors ranging from offensive or threatening language to homicide. In recent years, additional descriptions of other forms of workplace violence have been added. Horizontal violence or lateral aggression has been used to describe aggressive and destructive behavior of co-workers against each other. Other terms associated with this type of violence include bullying and interpersonal conflict. These behaviors exist in what has been termed toxic workplacesIncivility includes a wide range of behaviors from ignoring others, to rolling one’s eyes, to yelling, and eventually to personal attacks, both physical and psychological. Both types of workplace violence are unacceptable.

Scope of the Problem

The true scope of workplace violence in health care is difficult to determine. The main source of data for workplace violence and injuries is the Bureau of Labor Statistics (BLS). A BLS report (2012b) indicated healthcare workers, especially nurses, experience high rates of violence compared to workers in most other industries. In 2011, 203 workplace homicides occurred in the category of healthcare and social assistance workers (BLS, 2012a). Although this number is a concern, the incidence of fatal injuries is low when compared with the combined number of fatalities or for those in other types of industries. Underreporting, varying data collection methodologies, and source data give a wide range of estimates for violence against and among healthcare workers (Gacki-Smith, Juarez, & Boyett, 2009Gates, Gillespie, & Succop, 2011Hartley & Ridenour, 2011Stokowski, 2010). Underreporting violence in health care is thought to be related to a perception within nursing that assaults with or without injuries are “part of the job.” Some nurses may be fearful to report violence thinking they could have prevented it or they are pessimistic about the response they will receive from supervisors or managers. Similar perceptions exist related to lateral violence or incivility. Nurses tend to feel that this animosity is the predictable consequence of people working together and something they must get used to if they wish to remain in the profession (Dellasega, 2011). Workplace bullying is often reported to result in enough psychological distress to nurses to cause them to leave the profession (Dellasega, 2009). Bullying also interferes with teamwork and communication and can impact patient safety. These concerns underscore the urgent need for prevention of both patient-to-nurse and nurse-to-nurse violence.

The Cost of Workplace Violence

Our knowledge of the scale of workplace violence remains incomplete because no consistent system of data collection exists. Data regarding the less severe forms of workplace violence are particularly sparse. Even less clear is the financial toll workplace aggression exacts on businesses. Lewis and Malecha (2011) calculated lost productivity due to workplace violence at $11,581 per nurse per year. In a survey by Rosenstein (2010), participants indicated that 80% had witnessed disruptive behaviors and more than one third knew a nurse who left employment because of it. The direct cost of recruiting and hiring a new nurse is estimated at between $60,000 and $100,000. Pearson and Porath (2009) suggested that estimates of the cost of workplace violence should also consider how many times people report they are sick when they are really avoiding bad behavior. This absenteeism, and the decreases in productivity because employees no longer feel comfortable in the environment, are difficult to quantify but need to be considered. When added together, these costs mount rapidly.

Incivility and its associated disruptive behaviors have also been determined to have a negative effect on the delivery of high-quality patient care. The Joint Commission (TJC) in its root cause analysis of sentinel events found that nearly 70% of the events impacting patient care quality could be traced back to a communication problem (TJC, 2008). The cost of poor communication among healthcare providers has been estimated at $12 billion annually (Agarwal, Sands, & Diaz-Schneider, 2008). Although not all communication problems are related to incivility, many nurses have reported uncivil communication as a problem. Studies have yet to capture the full cost of workplace violence in its many forms, and more data are needed to assess the economic impact of violence in health care and the effectiveness of intervention strategies (see the Research Perspective).

Research Perspective

Resource: Purpora, C. & Blegen, M.A. (2012). Horizontal violence and the quality and safety of patient care: A conceptual model. Nursing Research and Practice, 2012:306948.

For many years nurses have voiced concern about horizontal violence in the clinical setting and its impact on care, but researchers had no framework for linking workplace violence with quality outcomes. Additionally, no direct empirical links between horizontal violence, disruptive behavior, dysfunctional communication, and patient care had been identified. The researchers proposed a conceptual model for horizontal violence and the quality and safety of patient care that was based on four theories:

These four theories, linked for the first time in this conceptual model, illustrate how horizontal violence can impact quality and safety in the healthcare setting.

Implications for Practice

This framework provides a foundation to guide research in the area of workplace violence, patient safety, and quality. The model’s propositions generate other questions based on empirical links that are meant to stimulate new research to bridge the gap in our understanding of the consequences of workplace violence.

Ensuring a Safe Workplace

Although no national legislation or federal regulations specifically address the prevention of workplace violence, OSHA has published voluntary guidelines for workers in healthcare and several other high-risk professions. Although employers are not legally obligated to follow these guidelines, the Occupational Safety and Health Act (OSH Act, 1970) mandates that, in addition to complying with hazard-specific standards, all employers have a general duty to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm. An organization can be cited if its leaders fail to address such hazards. Because healthcare workers are at increased risk, OSHA (2004) developed Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers to assist healthcare organizations in developing violence prevention plans. Several states are also enacting or developing laws, standards, or recommendations that address healthcare workplace security and safety. Many of these laws have been created with strong support from state-based nursing organizations with support from the American Nurses Association (ANA) and other professional healthcare organizations. A few states have passed laws that enhance criminal penalties for crimes committed against licensed or certified health professionals (ANA, 2012) (Figure 25-1). Many other states have or are working on legislation requiring healthcare organizations to have a workplace violence prevention plan. In 2010, TJC issued a sentinel event alert that identifies the issue of preventing

Figure 25-1 The American Nurse Association’s Nationwide State Legislative Agenda for workplace violence, April 2012.

violence in the health care setting should be a priority for leaders. It notes that problems in the area of policy and procedure, inadequate assessment of the environment, and lack of education and training contribute to the majority of issues related to violence. TJC’s Environment of Care standard requires healthcare facilities to have a plan describing how the institution provides for security of patients, visitors, and staff.

Making a Difference

So what is the nurse in a leader, manager, or follower role to do given the serious and complex issue of violence in the workplace? Making a difference includes promotion of an organizational culture of safety and civility, development and implementation of a safety strategy, and personal strategies to prevent being victimized by violence in any setting are critical.

Prevention Strategies

The old adage “an ounce of prevention is worth a pound of cure” is particularly relevant when dealing with workplace violence. Preventing even one act of violence can save money and time and diminish the possible negative psychological impact of such an event. The costs from lost work time and wages, reduced productivity, medical costs, workers’ compensation payments, and legal and security expenses may be difficult to estimate but are clearly excessive when compared with the cost of prevention. Other future costs of workplace violence include increased staff turnover rates. Loss of the organizational investment required to train qualified staff and departure of experienced existing staff can increase operating expenses and reduce the quality of care. By taking a proactive approach that includes preventing violence, organizations can also prevent being victimized. To address the issue of violence, it is necessary to have a broad understanding of types of violence that may be encountered and the signs that portend a potentially violent situation. In short, prevention is the right thing to do.

Types of Violence

Since 1990, the University of Iowa Injury Prevention Research Center (IPRC) has been one of 11 injury “Centers of Excellence” funded by the National Center for Injury Prevention and Control, a branch of the Centers for Disease Control and Prevention (CDC). Workplace violence has been one of their research focus areas (IPRC, 2001). The university collects and uses epidemiologic data on groups at high risk in order to develop prevention strategies and training to control and prevent injuries. In their investigations, they categorize workplace violence into four types (Box 25-1). These categories can be very helpful in the design of strategies to prevent workplace violence, because each type of violence requires a different approach for prevention and acknowledges the fact that some workplaces may be at higher risk for certain types of violence. Understanding the types of violence allows leaders to conduct a more focused risk assessment based on what types of crimes may occur.

Risk Assessment

Although anyone working in health care is at risk for becoming a victim of violence, those with direct

Box 25-1 Categories of Workplace Violence

Criminal Intent (Type I): The perpetrator has no legitimate relationship to the business or its employees and is usually committing a crime in conjunction with the violence. These crimes can include robbery, shoplifting, and trespassing. The vast majority of workplace homicides (85%) fall into this category.

Customer/Client (Type II): The perpetrator has a legitimate relationship with the business and becomes violent while being served by the business. This category includes customers, clients, patients, students, inmates, and any other group for which the business provides services. A large proportion of customer/client incidents are believed to occur in the healthcare industry, in settings such as nursing homes or psychiatric facilities; the victims are often patient caregivers. Police officers, prison staff, flight attendants, and teachers are some other examples of workers who may be exposed to this kind of workplace violence.

Worker-on-Worker (Type III): The perpetrator is an employee or past employee of the business who attacks or threatens another employee(s) or past employee(s) in the workplace. Worker-on-worker fatalities account for approximately 7% of all workplace violence homicides.

Personal Relationship (Type IV): The perpetrator usually does not have a relationship with the business but has a personal relationship with the intended victim. This category includes victims of domestic violence assaulted or threatened while at work.

From Iowa Injury Prevention Research Center. (February 2001). Workplace violence: A report to the nation. University of Iowa—Iowa City. Retrieved February 15, 2013, from

patient contact are at higher risk. The BLS (2012b) reports healthcare workers in hospitals, specifically those in the emergency department, are at particularly high risk. Violence is also a frequent occurrence in psychiatric and geriatric settings. Unlike in other settings, hospital violence differs in that it is usually the result of patients or their family members feeling frustration or anger. This is usually related to feelings of vulnerability, stress, and loss of control that accompany illness. Many factors have been identified that can increase the risk for violence erupting in healthcare facilities. Risk factors identified in OSHA’s guidelines (2004) are listed in Box 25-2. Other risk factors for violence include the location of the facility, its size, and the type of care provided. Facilities in inner-city areas that serve a wide variety of the disadvantaged, especially those with mental illness or a history of violent behavior or those who are under the influence of drugs or alcohol, are at increased risk for violence to occur. Reviewing reports of violent

Box 25-2 Risk Factors for Violence in Healthcare Facilities

  • Work in understaffed situations, especially during visiting hours and meal times
  • Transportation of patients between areas in a facility
  • Long waits for patient care
  • Overcrowded, uncomfortable waiting areas
  • Solo work or in isolation from other staff
  • Solo work with patients in areas with no back-up or way to get assistance, such as communication devices or alarm systems
  • Poor environmental design
  • Inadequate security
  • Lack of staff training in handling potentially violent situations
  • Lack of policies for preventing and managing crises with potentially violent individuals
  • Unrestricted movement of patients or visitors
  • Poorly lit corridors, rooms, parking lots, or other areas
  • Prevalence of handguns or other weapons among patients, their families, or friends
  • Increased presence of gang members, drug or alcohol abusers, trauma patients, or distraught family members
  • Use of hospitals or healthcare facilities for holding criminals, violent individuals, and the acutely mentally disturbed
  • Chronically mentally ill patients being released without adequate resources for follow-up care
  • Availability of money or drugs within the facility

Adapted from Occupational Safety & Health Administration (OSHA). (2004). Guidelines for preventing workplace violence for health care and social service workers. Retrieved February 15, 2013, from

incidents reveals they often take place during times of high activity and interaction with patients, such as at mealtimes and during visiting hours and patient transportation. Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, or use of tobacco or alcohol.

Similar to the nursing process, prevention of workplace violence begins with a systematic assessment. Assessing risk and planning for prevention of workplace violence call for input and expertise from a variety of staff. A risk assessment based on an interdisciplinary team approach to workplace violence prevention is often the most effective. A team with representation from administration, staff, security, facilities engineering, human resources, legal counsel, and risk management is needed to address risks from all perspectives. A worksite assessment involves a step-by-step, common sense look at the facility

Box 25-3 Workplace Violence Program Checklists

OSHA and ANA have provided comprehensive checklist documents that can assist leaders and managers in conducting an organizational workplace violence assessment. The checklist titles are provided here. The checklists provide detailed step-by-step instructions to conduct an in-depth assessment and establish a monitoring program. To see the complete document, go to (OSHA Publication No. 3148-01R 2004).

  • Checklist 1:Organizational Assessment Questions Regarding Management Commitment and Employee Involvement
  • Checklist 2:Analyze Workplace Violence Records
  • Checklist 3:Identifying Environmental Risk Factors for Violence
  • Checklist 4:Assessing the Influence of Day-to-Day Work Practices on Occurrences of Violence
  • Checklist 5:Post-Incident Response
  • Checklist 6:Assessing Employee and Supervisor Training
  • Checklist 7:Record-keeping and Evaluation

Adapted from American Nurses Association: Promoting Safe Work Environments for Nurses, 2002. From Occupational Safety and Health Administration (OSHA). (2004). Guidelines for preventing workplace violence for health care and social service workers (OSHA Publication No. 3148-01R). Washington, DC: U.S. Department of Labor (

and the surrounding areas for existing problems and potential hazards. OSHA’s guidelines (2004) provide a comprehensive assessment with checklists and forms developed by the ANA to assist with the process. These are helpful to managers and leaders who are not familiar with this type of assessment (Box 25-3). The ECRI Institute (, a federally designated Patient Safety Organization, and the International Association for Healthcare Security & Safety (IAHSS) ( also have numerous resources and tools to assist healthcare organizations in creating security management plans to reduce the potential for violence.

When looking at possible threats or hazards, those from within an organization also must be considered. Determining if current employees pose a danger in the workplace is a critical factor that is often overlooked. In addition to personal and psychological factors, behaviors can be observed in employees that may be related to violence or aggression in the workplace (Paludi, Nydegger, & Paludi, 2006). The most obvious of these is a previous history of aggression and substance abuse. Screening potential employees through drug testing, background checks, and references can help reduce these risks.

Firing Right

Organizational conditions or outcomes may magnify the potential for violence to erupt. This includes prolonged high levels of stress or factors that create what is known as a toxic workplace environment. Rapid change, layoffs, changes in schedules and workloads, or wage freezes could have this effect. The employment situation with the highest potential to create this kind of stress is the firing or layoff process. Most organizations have specific protocols that deal with the process of terminating employees, because firing is cause for strong emotions that can increase the potential for violence. Managers may be responsible for staff terminations in some organizations; others require this process to occur in the human resources department. Either approach requires close collaboration between nursing and human resources. The goal always is to conduct the process in the most professional manner possible, although organizational rules may specify a detailed procedure. A few tips on how to prepare for this potentially problematic situation are provided in Box 25-4.

Unfortunately no profile or litmus test exists to identify whether a current employee might become violent. Employers and employees alike must remain alert to problematic behavior that, in combination, could point to possible violence. Because no single behavior suggests a greater potential for violence, behaviors

Box 25-4 Firing Right

Firings should be planned with forethought for any potential problems. Steps should be taken to avoid potential violence during employee separation. A key step is protecting the employee’s dignity and avoiding humiliation. The reasons for termination should be clear and leave no room for debate. All details should be arranged, including timing, the room used, and who is present. The room should provide privacy but not contain any objects that could be used as a weapon. The person being terminated should not be blocked from accessing the exit door. Termination notices and severance checks along with any other documentation should be on hand. Arrangements should be made to clean out the person’s desk or locker. No option should be available for the person to return to the worksite. This saves everyone from embarrassment and any potential scenes. It is important to try to determine how the person will react to make appropriate arrangements. If a perceived need exists, a security officer or off-duty police officer can be called to stand by.

Adapted from Winfeld, L. (2001). Training tough topics. New York: American Management Association.

must be looked at in totality. Problem situations, circumstances that may heighten the risk of violence, can involve a particular event or employee or the workplace as a whole.

Exercise 25-1

Assess several clinical settings for workplace violence risks. Can you identify any based on what you have read? What security measures are currently in place? Can any of them be improved? How safe would you feel in the different geographical areas?

Once the risk assessment is completed, the next step is to analyze the data and prioritize the problems that need to be addressed. Priorities can be established by asking a few basic questions: What are the risks? Who might be harmed and how? What is the level of risk? What measures need to be taken to reduce or eliminate risk? Do we need to implement changes now or later? Once the priorities are set, the business of designing or improving prevention programs can begin. (See the “Developing a Safety Plan” section on p. 475.)

Horizontal Violence: The Threat from Within

In 2008, TJC strengthened requirements in their leadership standards for dealing with disruptive behavior. Citing studies that suggest intimidating and disruptive behaviors contribute to poor patient satisfaction and preventable adverse outcomes, the standards call for codes of conduct and processes for managing such behaviors. Horizontal or lateral violence describes a wide variety of behaviors, from verbal abuse to physical aggression between co-workers. This term, though commonly used, may be limiting because it suggests the violence is perpetrated between those at the same level of authority. It may be better termed relational aggression (Dellasega, 2009Dellasega, 2011), which can occur between people at different levels. This includes bullying behavior and intimidation. Horizontal violence or bullying is used in this section because these are terms common in the literature. Horizontal violence and its effects have been reported in the nursing literature for more than 20 years. In a review of five research studies on horizontal violence, researchers (Woelfle & McCaffrey, 2007) found that horizontal violence is experienced by not only nursing students but also the novice and veteran nurses. Many of the research reports found infighting and a general lack of support of nurses for each other to be common occurrences. The studies also indicated that new graduates were likely to experience horizontal violence, which resulted in high absentee rates and thoughts of leaving nursing after their first year. This caused the researchers to ask this question: How can nurses treat patients kindly and give them the respect they need when they treat each other so poorly? In light of the looming nursing shortage, these consistent findings among nurses were cause for concern.

Many theories exist as to why horizontal violence is prevalent in nursing, ranging from nursing’s traditional hierarchical structure, to oppression of nursing as a profession (Roberts, Demarco & Griffin, 2009), to feminism (Farrell, 2001). However, workplace aggression is common in other professions and is most likely the result of complex individual, social, and organizational characteristics (Papa & Venella, 2013). Regardless of the reasons why it happens, the concerns are that impaired personal relationships between nurses at work can cause errors, accidents, and poor work performance and may play a significant role in attrition (Johnson, 2009Lewis & Malecha, 2011Porto & Lauve, 2006Purpora & Blegen, 2012Roberts, Demarco, & Griffin, 2009Shields & Wilkins, 2009TJC, 2008). There is no place in a professional practice environment for lateral violence and bullying among nurses or between healthcare professionals. These disruptive behaviors are toxic to the nursing profession and have a negative impact on retention of quality staff. Horizontal violence and bullying should never be considered normally related to socialization in nursing nor be accepted in professional relationships. All healthcare organizations should implement a zero tolerance policy related to disruptive behavior, including a professional code of conduct and educational and behavioral interventions to assist nurses in addressing disruptive behavior (Papa & Venella, 2013). A number of other state and national nursing organizations also have issued statements regarding the detrimental effect of disruptive behavior on both patients and nurses and have called for solutions to address the problem. TJC (2008) revised its standards for disruptive behavior calling for identification of manifestations of abuse and violence in healthcare organizations. Holloway and Kusy (2010) provided practical organizational strategies to address toxic behaviors to change the culture of incivility (see the Literature Perspective). With professional groups calling for change from within nursing and accreditation groups calling on administration to fix problems, we must examine how to implement a change. See for resources.

Literature Perspective

Resource: Holloway, L.E. & Kusy, M.E. (2010). Disruptive and toxic behaviors in healthcare: Zero tolerance, the bottom line, and what to do about it. Medical Practice Management25(6), 335-340.

This article provides the results of a survey of over 400 healthcare leaders representing 39% of healthcare organizations. The authors found that 94% of those surveyed had to deal with some form of incivility or toxic behavior at work. Citing the literature that indicates toxic environments and disruptive behavior impact patient safety and quality of care, the authors provide a whole system approach that is tailored to complex healthcare environments. The Toxic Organization Change System (TOCS) addresses incivility at the level of the organization, the team, and the individual. It describes specific strategies that can be used preventively or remedially. At the organization level, the main strategies include establishing a set of values that call for professionalism, courtesy, and respect for all. Defining these values from the ground up is an important activity to bring together stakeholders from across the organization. Once the values are established they are incorporated into the performance appraisal process. Managers are trained how to evaluate and reinforce these behaviors and values in both formative and summative stages. The team’s strategy consists of identifying individuals or processes that perpetuate toxic cultures and working to rebuild positive norms and functional teams in those environments. This includes use of a 360-degree team assessment and facilitation to improve communication and address toxic behavior. Individual strategies involve managers providing regular feedback, establishing goals and working on professional growth and development with their staff. This includes instituting clear consequences for toxic behaviors and being willing to terminate staff members who perpetuate toxic culture.

Implications for Practice

Addressing a toxic culture requires training in conflict management, leadership, communication, and team building. To move an organization from a culture of incivility to one of respect is no easy task but in this era of healthcare reform, tight budgets, and need for better healthcare outcomes, it is work that organizations must do to meet their bottom line and to ensure nurses feel valued, respected, and safe.

Increasing Awareness of Horizontal Violence

The causes of horizontal violence within nursing are pervasive and long-standing. No definitive actions have been shown to significantly decrease the occurrence of violence. One thing is certain—recognizing the tendency toward bullying, harassment, or intimidation in the workplace is a prerequisite to preventing it. The true depth of the problem is difficult to determine. Commonly, horizontal violence is significantly underreported for any number of reasons, and organizational leaders often are not aware of its extent. To get an accurate picture of employee satisfaction and concerns about bullying and other forms of violence, anonymous surveys should be conducted. Surveying staff can help identify problems and provide a basis for developing appropriate interventions. To understand if violence or intimidation is a reason for leaving, organizations should conduct exit interviews with the assurance that the information will remain confidential if an employee fears retaliation. This is an important step in gauging if the problem is bullying or intimidation by managers. Johnson (2009) found that 50% of respondents indicated that they were bullied by their manager or director. The researcher suggested that when management is part of the problem, victims have a harder time feeling they have adequate support to end the negative cycle of violence. This may serve to perpetuate the existence of a toxic environment within an organization.

Nursing leaders can set the stage for addressing workplace bullying by examining and addressing their own behaviors and by fostering an environment that encourages open communication and collaboration. With personal insight in hand, they can lead their nurses to examine their own behavior and work together to create a work environment in which bullying is not tolerated. An atmosphere of openness can encourage dialog and brainstorming to find solutions. Lack of support leads many victims of bullying to decide that the best alternative is to leave the organization and to give this advice to others who find themselves in similar situations (Johnson, 2009). Employees who are supported in reporting workplace aggression may feel they have options other than leaving. The worst outcome would be for the nurse to feel that using formal and informal organizational channels to bring about an end to bullying was emotionally draining, time-consuming, and futile.

Organizational culture and working conditions also can contribute to bullying and horizontal violence. High stress levels, inadequate staffing, organizational change, and unrealistic expectations can contribute to a toxic environment and foster increased incivility among staff. A culture of zero tolerance for horizontal violence is an effective leadership strategy to prevent its occurrence. For organizations that have tolerated horizontal violence, developing a new shared set of values and goals that promote empowerment, communication, and collaboration is a positive step (Longo, 2007). Leaders need to set the tone for establishing a civil workplace in which all members are treated with respect and in which conflicts are dealt with in a healthy and open manner (Holloway & Kusy, 2010). TJC (2010) suggests 11 actions that can be used as a blueprint for developing a program to address disruptive behavior within organizations (Box 25-5). No violence prevention program will work if management does not endorse it.

Encouragement to report violence in all its forms is crucial to understanding the root of the problem and implementing plans to eradicate it. Acts of good faith by organizational management in supporting staff include a policy of nonretaliation for reporting. Making sure that reporting is easier and doing an impartial investigation is critical. Ensuring appropriate discipline for identified problems that is proportional to the seriousness of the event goes a long way in building employee trust. People are the greatest resource in an organization, and wise management invests time and effort in addressing culture, safety, and satisfaction of nursing staff. Finally, organizations that implement interventions aimed at addressing workplace bullying need to collect data to determine whether these interventions are successful.

Nurses themselves must work to actively develop a culture in which violence is not tolerated. This involves a critical self-assessment of personal behaviors and looking for patterns or situations that could trigger subtle types of lateral aggression. Awareness and understanding of the types of horizontal violence can help them to actively not participate in the behaviors. This is a powerful tool in eradicating a toxic environment. Many subtle forms of horizontal violence that may not be readily recognized as violent behavior but are psychologically and emotionally harmful are listed in Box 25-6. Recognizing these behaviors and efforts to eliminate them can create a healthier working environment

Box 25-5 The Joint Commission Suggested Actions

  • Educate all team members—both physicians and nonphysician staff—on appropriate professional behavior defined by the organization’s code of conduct.
  • Hold all team members accountable for modeling desirable behaviors, and enforce the code consistently and equitably among all staff, regardless of seniority or clinical discipline, in a positive fashion through reinforcement as well as punishment.
  • Develop and implement policies and procedures/processes appropriate for the organization that address the following:
    • “Zero tolerance” for intimidating and/or disruptive behaviors
    • Medical staff policies regarding intimidating and/or disruptive behaviors
    • Reducing fear of intimidation or retribution and protecting those who report or cooperate in the investigation of intimidating, disruptive, and other unprofessional behavior
    • Responding to patients and/or their families who are involved in or witness intimidating and/or disruptive behaviors
    • How and when to begin disciplinary actions (e.g., suspension, termination, loss of clinical privileges, reports to professional licensure bodies)
  • Develop an organizational process for addressing intimidating and disruptive behaviors that solicits and integrates substantial input from an interdisciplinary team including representation of medical and nursing staff, administrators, and other employees.
  • Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior, and conflict resolution.
  • Develop and implement a system for assessing staff perceptions of the seriousness and extent of instances of unprofessional behaviors and the risk of harm to patients.
  • Develop and implement a reporting/surveillance system (possibly anonymous) for detecting unprofessional behavior.
  • Support surveillance with tiered, nonconfrontational interventional strategies, starting with informal “cup of coffee” conversations directly addressing the problem and moving toward detailed action plans and progressive discipline, if patterns persist.
  • Conduct all interventions within the context of an organizational commitment to the health and well-being of all staff, with adequate resources to support individuals whose behavior is caused or influenced by physical or mental health pathologies.
  • Encourage interdisciplinary dialogs across a variety of forums as a proactive way of addressing ongoing conflicts, overcoming them, and moving forward through improved collaboration and communication.
  • Document all attempts to address intimidating and disruptive behaviors.

The Joint Commission (2008). Behaviors that undermine a culture of safety. Sentinel Event Alert. 40. Retrieved May 15, 2013, from

Reprinted with permission. Copyright © 2009.

Box 25-6 Common Subtle Behaviors in Nurse-Nurse Bullying

  • Giving a nurse “the silent treatment”
  • Spreading rumors
  • Using humiliation and put-downs, usually regarding a nurse’s skills and abilities
  • Failing to support a nurse because you do not like him or her
  • Excluding a nurse from on-the-job or off-the-job socializing
  • Repeating information shared by one nurse out of context so that it reflects badly on him or her
  • Sharing confidences you were asked to keep private
  • Making fun of another nurse’s appearance, demeanor, or another trait
  • Refusing to share information with another nurse or otherwise setting him or her up to fail
  • Manipulating or intimidating another nurse into doing something for you
  • Using body language (e.g., eye rolling or head tossing) to convey an unfavorable opinion of someone
  • Saying something unfavorable and then pretending you were joking
  • Calling names
  • Teasing another nurse about his or her lack of skill or knowledge
  • Running a smear campaign or otherwise trying to get others to turn against a nurse

Modified from Dellasega, C. (2009). Bullying among nurses. American Journal of Nursing, 109(1), 52-58.

that is based on mutual respect. In the book, When Nurses Hurt Nurses: Recognizing and Overcoming the Cycle of BullyingDellasega (2011) explores the nature of relational aggression within nursing and provides practical strategies to deal with bullying. The ANA (2010) also has resources, including a pocket card on bullying and lateral violence that gives examples of bullying behavior and possible responses to help nurses identify and deal with bullying (Figure 25-2).

Exercise 25-2

Think about your behavior in the workplace. Have you ever acted in a way that might be described as lateral aggression or horizontal violence? How might you guard against such behaviors? Do you think you could confront a co-worker participating in an act of lateral aggression? What would you say?

Participating in violence prevention education can prepare staff to deal with situations that contribute to bullying or intimidation.

Figure 25-2 American Nurses Association (2010). Hostility, abuse and bullying the workplace. 2010 House of Delegates Resolution. Bullying and Lateral Violence: Examples of Bullying Behavior Pocket Card.

(From AboutNN/Tip-Card-Bullying-and-Lateral-Violence-ANA.pdf.)


Education on workplace violence should be provided to all employees but initially to supervisors, whose support is crucial to the success of the program (Papa & Venella, 2013). Interventions aimed at nurse leaders regarding ways to change organizational climates that perpetuate bullying have proved to be a better option than directing education at individual nurses (Johnson, 2009). Education should focus on identifying the potential for violence, managing violent situations, and practicing behavioral and de-escalation techniques. In some settings, more focused training on applying restraints and take-down techniques would be appropriate. This type of training should start in nursing school to prepare those going into the workforce for the realities of their day-to-day work. Training needs to be annual and ongoing and needs to address topics that have been identified through survey, reporting, and data analysis.

Participating in violence prevention education can prepare staff to deal with situations that contribute to bullying or intimidation (Hartley, Ridenour, Craine, & Costa, 2012). In her study, Griffin (2004) used a cognitive behavior technique called cognitive rehearsal as an intervention for lateral violence. Cognitive rehearsal involves listening and then holding the information provided in the mind to allow time to process a response in a way the staff have been taught. This change in the way they responded allowed opportunities to change negative perceptions and confront laterally violent nurses. This opens the door to better communication and has been shown to help nurses’ better cope with potentially violent situations (Dellasega, 2011).

Developing a Safety Plan

No “one-size-fits-all” strategy exists for an effective safety and violence prevention program or plan. Effective plans may share a number of features, but a good plan must be tailored to the needs, resources, and circumstances of a particular employer and a particular work force. Activities related to developing a good prevention program fall into three domains: administrative, environmental, and interpersonal.


To develop an effective workplace violence strategy, support from the top must be present. If an organization’s senior executives are not truly committed to a prevention program, it is unlikely to be effectively implemented. Part of the organization’s responsibility is to provide a written program for job safety and security. Developing and maintaining a program requires time and resources. Allocations need to be made for a multidisciplinary safety committee, regular worksite analysis, prevention activities, safety and health training, documentation, and evaluation of the overall program. The program should outline the organization’s commitment to a safe work environment and the staff’s involvement in the plan. The program should be proactive, not reactive, and have clear goals and objectives to prevent workplace violence that is specific to the organization and its characteristics. Personnel, work environments, business conditions, and society all change and evolve. A successful prevention program must change and evolve with them. Policies and practices should not be set in concrete and should be regularly evaluated to determine if they are keeping current with a changing environment. The administration needs to communicate the safety plan effectively and consistently enforce policy to ensure that the staff believes safety is of paramount importance.

A written workplace violence policy sets the standard for acceptable workplace behavior and should be available to all employees. The statement should affirm the organization’s commitment to a safe workplace, employees’ obligation to behave appropriately on the job, and the employer’s commitment to take action on any employee’s complaint regarding harassing, threatening, and violent behavior. The statement should be in writing and distributed to all employees. In defining acts that will not be tolerated, the statement should make clear that not only physical violence but also threats, bullying, harassment, and weapons possession are against policy and are prohibited.

Plans should consider the workplace culture: work atmosphere, relationships, and management styles. Policies on workplace conduct should be written to clearly state the employer’s standards and expectations. Attention should be paid to elements in an organization’s culture that foster a toxic work environment, such as the following:

  • Tolerance of bullying or intimidation
  • Lack of trust among workers
  • Lack of trust between workers and management
  • High levels of stress, frustration, and anger

The organization should be actively addressing root causes of problems to reduce the potential for frustration to lead to violence. If significant problems are identified, disciplinary actions for violent behavior of any kind must be proportionate, consistent, reasonable, and fair. Erratic or arbitrary discipline, favoritism, and a lack of respect for employees’ dignity and rights are likely to undermine an employer’s violence prevention efforts. Workers who perceive an employer’s practices as unfair or unreasonable will be more unlikely to report problems. Lack of reporting allows unfavorable situations to continue with many negative impacts. When a complaint is made or an incident occurs, an incident response team should conduct or ensure a thorough investigation of the facts and, based on the results, determine appropriate disciplinary measures. Likewise with patients or visitors to a healthcare facility, expectations about acceptable behavior and the consequences of violent behavior should be clearly communicated. Strong administrative commitment to a safety plan serves to reaffirm the employer’s commitment to a workplace free from threats and violence.


Engineering controls and other environmental adaptations to remove safety hazards can be very effective. Deciding what interventions are needed is the “intelligence” work of organizations. The countermeasures applied can reduce potential risks. The selection of measures to be used is based on the hazards identified in the security risk analysis. Some environmental interventions, such as providing better lighting or restricting access to care areas, can have a significant impact on safety at very low cost. The types of interventions that may be identified by security risk assessment are listed in Box 25-7.

Administrative and work practice controls can also be evaluated to determine the effect on how staff members perform their jobs and how changes in procedures can help reduce the potential for violent incidents. Any process changes that reduce waiting times or improve customer service can help reduce frustration that may lead to violent outburst. Staff training on handling aggressive behavior and how to respond in violent events is discussed in the next section.

Box 25-7 Environmental Safety Controls

  • Assess any plans for new construction or physical changes to the facility or workplace to eliminate or reduce security hazards.
  • Install and regularly maintain alarm systems and other security devices, panic buttons, handheld alarms or noise devices, cellular phones, and private channel radios where risk is apparent or may be anticipated. Arrange for a reliable response system when an alarm is triggered.
  • Provide metal detectors—installed or handheld, where appropriate—to detect guns, knives, or other weapons, according to the recommendations of security consultants.
  • Use a closed-circuit video recording for high-risk areas on a 24-hour basis. Public safety is a greater concern than privacy in these situations.
  • Create security alert overhead paging protocols and response teams.
  • Place curved mirrors at hallway intersections and concealed areas.
  • Enclose nurses’ stations and install deep service counters or bullet-resistant, shatterproof glass in reception, triage, and admitting areas or patient service rooms.
  • Provide employee “safe rooms” for use during emergencies.
  • Establish “time-out” or seclusion areas with high ceilings without grids for patients who “act out,” and establish separate rooms for criminal patients.
  • Provide comfortable client or patient waiting rooms designed to minimize stress.
  • Ensure that counseling or patient care rooms have two exits.
  • Lock doors to staff counseling rooms and treatment rooms to limit access.
  • Arrange furniture to prevent entrapment of staff.
  • Use minimal furniture in interview rooms or crisis treatment areas, and ensure that it is lightweight, without sharp corners or edges, and affixed to the floor, if possible. Limit the number of pictures, vases, or other items that can be used as weapons.
  • Provide lockable and secure bathrooms for staff members separate from patient/client and visitor facilities.
  • Lock all unused doors to limit access, in accordance with local fire codes.
  • Install bright, effective lighting, both indoors and outdoors.
  • Replace burned-out lights and broken windows and locks.
  • Keep automobiles well maintained if they are used in the field.
  • Lock automobiles at all times.
  • Provide administrative controls such as codes for door access in staff or restricted areas.
  • Improve processes to decrease wait times or other activities that create frustration for patients and family members.

Adapted from American Nurses Association: Promoting Safe Work Environments for Nurses, 2002. From Occupational Safety and Health Administration (OSHA). (2004). Guidelines for preventing workplace violence for health care and social service workers (OSHA Publication No. 3148-01R). Washington, DC: U.S. Department of Labor (


Little research has been done on the effectiveness of training staff to anticipate, recognize, and respond to conflict and potential violence in the workplace. Helping managers to be alert to warning signs of conflict and to know how to respond when indications of a problem arise seems to be beneficial (Johansen, 2012). Training about workplace violence prevention will vary according to different employee groups and issues specific to their work environment. Training should be provided to new and current employees, supervisors, and managers. All training should be conducted on a regular basis and cover a variety of topics, including the following:

  • The workplace violence prevention policy, including reporting requirements
  • Risk factors that can cause or contribute to threats and violence
  • Early recognition of warning signs of problematic behavior
  • Ways of preventing or defusing volatile situations or aggressive behavior, where appropriate
  • Information on cultural diversity to develop sensitivity to racial and ethnic issues and differences
  • A standard response action plan for violent situations, including availability of assistance, response to alarm systems, and communication procedures
  • The location and operation of safety devices such as alarm systems, along with the required maintenance schedules and procedures
  • Ways to protect oneself and co-workers, including use of a buddy system
  • Policies and procedures for reporting and record-keeping
  • Policies and procedures for obtaining medical care, counseling, workers’ compensation, or legal assistance after a violent episode or injury

Training employees in nonviolent response and conflict resolution has been suggested to reduce the risk that volatile situations will escalate to physical violence. Training that addresses hazards associated with specific tasks or worksites and relevant prevention strategies is also critical. Training should not be regarded as the sole prevention strategy but, instead, as a component in a comprehensive approach to reducing workplace violence. To increase vigilance and compliance with stated violence prevention policies, training should emphasize the appropriate use and maintenance of protective equipment, adherence to administrative controls, and increased knowledge and awareness of the risk of workplace violence.

No matter how thorough or well-conceived, preparation will not be effective in an emergency if no one remembers or implements the plan. Training exercises should be a regular part of the process. Training must include managers and senior executives who will be making decisions in a real incident. Exercises must be followed by careful evaluation with rapid responses that fix whatever weaknesses have been revealed.

Exercise 25-3

Look at an organization’s workplace safety plan. Does it have a statement about zero tolerance for violent behaviors? Does it include instructions on how to report violent behavior? Has it been updated recently? Based on what you have read, do you think the plan is comprehensive?

Understanding the Potential for Violence

Though violent incidents can occur seemingly without warning, some theories allow us to assess and predict potential occurrences. Research by John Monahan (1981), a psychologist at the University of Virginia Law School, described basic mental and behavioral cycles and circumstances that can escalate over time into violence. The cycle or spiral has four parts:

  • An individual encounters a stressful event.
  • The individual reacts to the event with certain types of thoughts that are predisposed based on personality.
  • The thoughts lead to emotional responses.
  • These responses in turn determine the behavior used to respond to the situation.

Extreme stress may lead to a belief that violence is the only viable way to cope with the situation or to relieve the stress. The responses of the individuals involved can either de-escalate or escalate the situation, influencing the ultimate outcome. Awareness of this basic pattern can help manage the potential for violent situations. Understand that the individual’s perception of the stress is what precipitates the spiral. What seems like a minor issue to you may be a huge event for someone else depending on his or her subjective experience. Things as minor as a change in routine or seemingly small annoyances can be a trigger. The stressful event can become magnified when a person is not sure whether he or she has the resources to respond successfully to the stress. It then becomes important to appraise how a person responds to stressors, how he or she views the situation, and what he or she expects to happen.

If the individual is contemplating an assault, anything that can be done to improve communication and decrease frustration can have a significant impact. At this point, the perpetrator may be struggling to overcome internal barriers to lashing out. Taking advantage of this internal struggle and allowing the person a way to back down without embarrassment can de-escalate the situation. This takes good communications skills that can be taught and rehearsed. Another strategy is to not allow an environment that is conducive to a physical assault. In many cases, an assault will not take place in the presence of other staff, in a public area, or where surveillance cameras are present. If an attack is initiated, the goal is minimization of harm and control of the situation or escape.

Physical attacks often occur after several indicators have pointed toward the potential of violence. Case studies of violent behavior are filled with information that show that people felt threatened, intimidated, or unsafe in the presence of the person who later committed an act of violence. In his book, The Gift of Fear: Survival Signals That Protect Us From ViolenceDeBecker (2000) asserted that fear is an internal warning system, alerting us to potentially threatening situations. In interviews with survivors of violent attacks, they frequently related that they “had a bad feeling” about the situation or that they knew that something was not right. DeBecker postulates that the “gut feeling” or “intuition” is the result of rapid cognitive processing of a complex web of cues or patterns of behavior that the subconscious brain alerts to before the logical part of the brain has the chance to catch up. Learning to use this awareness has formed the basis for many self-defense and workplace violence trainings. Training on subtle clues as well as day-to-day experience in dealing with a variety of people can add to adeptness in reading situations and recognizing danger. Validating that this fear response is useful may help in situations in which that moment of trying to rationalize the fear can give a perpetrator the edge needed to carry out an attack. The trick is not only to listen to your intuition but also to look for behaviors that predict violence or to provide an opportunity for escape. Many overt cues may predict violence. Body language is the most significant of these cues. These are usually easy to identify and may include standing too close, threatening gestures, tense posture, furtive glances, and rapid or repetitive movements. Being aware of your body language can be a critical factor in keeping a situation from escalating. We are generally aware of the body language of others but may not recognize our own body language.

Assessing behaviors that may precede violence and any other clues about a person’s history such as mental illness and drug or alcohol abuse may also help predict violent behavior. Luck, Jackson, and Usher (2007) devised a system that helps identify observable behaviors that indicate the potential for violence. Through their research with emergency department personnel, they created five distinctive elements that portend violent behavior. They use the easily remembered acronym STAMP to outline cues for an assessment of the behaviors (Box 25-8).

Box 25-8 Stamp Assessment Components and Cues

Assessment Component Assessment Cue
Staring Prolonged glaring at the nurse while she/he is engaged in nursing practice
Tone and volume of voice Sharp or caustic retorts


Demeaning inflection

Increase in volume

Anxiety Flushed appearance


Rapid speech

Dilated pupils

Physical indicators of pain: grimacing, writhing, clutching body

Confusion and disorientation

Expressed lack of understanding about emergency department processes

Mumbling Talking “under their breath”

Criticizing staff or the institution just loudly enough to be heard

Repetition of same or similar questions or requests

Slurring or incoherent speech

Pacing Walking around confined areas such as a waiting room or bed space

Walking back and forth to the nurses’ area

Flailing around in bed

“Resisting” health care

From Luck, L., Jackson, D., & Usher, K. (2007). STAMP: Components of observable behavior that indicate potential for patient violence in emergency departments. Journal of Advanced Nursing, 59(1), 11-19, Blackwell Publishing Ltd.

Often a violent act is preceded by a threat. A threat may be explicit or veiled, spoken or unspoken, specific or vague. It may be an offhanded remark or comments made to people close to the patient or family that may suggest problematic behavior. Detecting threats and/or threatening behavior, evaluating them, and finding a way to address them are important keys to preventing violence. All staff members need to be educated on how to detect threatening behavior and how to report it. All threats should be evaluated to determine when someone is making a threat versus posing a threat. In most cases, a threat will not lead to a violent act, but it still requires a response. The goal of threat assessment is to determine its severity and plan an appropriate intervention.

Personal Safety Training

People are more likely to survive any life-threatening situation when they confront reality and develop a plan. This requires preparation and thinking logically. Frequent training and rehearsal of what to do in a particular situation can help remain clearheaded when fear kicks in. Knowing whom to call, what escape routes are available, and how to defuse violent situations provides readily accessible skills when violent events occur.

Most training on workplace violence prevention is based on basic self-defense techniques that are important for everyone to know. This type of training consists primarily of using common sense and awareness to avoid potentially dangerous situations. Key points are (1) being constantly aware of surroundings and (2) planning ahead or thinking about potential problems and how to respond. Knowing how to call for help or memorizing code names for emergency situations is part of this preparation. Assessing work areas for potential security problems and how to escape if trapped in particular areas is key. Running different scenarios mentally helps create more rapid and safer responses. Assessing how to respond in tense situations can be helpful and provide insight into personal behavior that would escalate a situation. Learning how to project confidence and not being afraid to yell for help are also simple self-defense techniques that everyone can use.

Other conflict-management techniques that can be taught include defusing the aggressive individual. This technique is grounded in basic therapeutic communication theory. The goal is to manage situations in which people experience an escalation of emotion that may lead to violence. De-escalation can reduce the level of tension to the point at which the person under stress can regain control and avoid violence. To defuse situations, remain rational in the face of the irrational. If the affected person senses a prospective victim is losing control, it will increase his or her anxiety and loss of control. Understanding how you handle your own stress can influence your ability to effectively de-escalate others. By practicing therapeutic communication techniques, it is possible to more readily assess the behaviors so that, in a crisis, you can use your skills without freezing. Most important to remember is to look and act calm even if such is not the case. Helping someone stay calm is often easier if you appear warm and approachable. The person you are de-escalating will notice and take cues from your behaviors, even if he or she is too irrational to hear your words.

People exhibit some identifiable elements of escalation when they become upset. Challenging authority or asking questions that may not seem related to the situation is one common behavior. Another is to refuse or balk when given directions. A person may also temporarily lose some control and use words he or she may not normally use. The agitated person may even become threatening or intimidating. This agitation can rapidly turn life-threatening, so it is important to gain control of the situation quickly. As the situation escalates, you must retain your professionalism. If you become defensive or irrational, the situation only gets worse. It is often easier to react in a professional manner if you are not alone. Using the buddy system can be an easy way to help you retain your professionalism and reduce the chance of injury. Caution must be used when additional people come into an aggressive situation. The aggressor may become more agitated if he or she feels that people are ganging up. On the other hand, a witness may cause the aggressor to reconsider his or her behavior and regain control. One way to help those who are out of control is to validate or empathize with them. When we empathize with others, we are considering their needs and feelings. Expressing empathy helps the other person feel understood. Often, repeating the feelings you hear rather than the content of what was said is a good strategy. This can highlight the speaker’s concerns and fears and may help him or her begin to mentally process what is happening. This validation is powerful in de-escalating a situation. Keeping a calm tone of voice and a relaxed posture can help an agitated person hear the content of your message. Another way to demonstrate we are in control and responsive is to make sure our words and actions are congruent. This means that our words and actions communicate the same thing and form a clear message. For example, nodding and paying attention to the person talking to you is congruent with both sending the message that you would like to hear more and that you are listening. Being incongruent or acting in a way that does not match your words may be interpreted as being untrustworthy or inauthentic. For example, saying “I want to help you” while looking repeatedly at your watch sends a mixed message to the person you are trying to help.

Body language can be used to de-escalate situations. Most communication is nonverbal and involves body language. A basic awareness of body language of people under stress is useful. For example, when someone is upset, his or her personal space tends to increase. The best way to ensure that you are not invading the personal space of others is to stand at an angle to the person, slightly outside his or her personal space (usually about 3 feet or so in the U.S. culture), rather than face to face. Your shoulders should be at about a 90-degree angle to the person to whom you are talking. Keep your arms relaxed and at your sides, and stand with your feet slightly parted. Again, if your body language is aggressive, it may further escalate a situation. You should also be aware of your relationship to an exit. An agitated person may become more aggressive if he or she feels his or her escape from an area is being blocked. You do not want to be the person blocking an exit route if the person does decide to attack. Gender and culture may influence a situation and how you use eye contact, touching, or head movements. It is also important to assess the body language of potentially violent persons, looking for clues as to what they may do next or when they may become violent. Pounding or clenching fists or pointing fingers may indicate the person is about to physically lash out. If these warning signs are present, it may be time to disengage and find help. If you are the one being threatened, any one of these techniques may buy the time needed to get out. The key is to recognize the signs and take action to de-escalate the situation.

Exercise 25-4

Have you ever received training from your employer on workplace violence? Would you feel comfortable asking for training from your manager? What type of training would you want?

After a Violent Event

Violence can and will occur despite best efforts at prevention. Like all violent crime, workplace violence creates ripples that go beyond what is done to a particular victim. It damages trust and the sense of security every worker has a right to feel while on the job. In that sense, everyone loses when a violent act takes place. When it does occur, leaders must be prepared to deal with the consequences by providing an environment that fosters honest communication and support. Lack of commitment in addressing violence can lead to economic loss in the form of high turnover rates, lost work time, damaged employee morale, and reduced productivity. In addition, the organization could face possible legal action from state and federal agencies, increased workers’ compensation payments, medical expenses, and possible lawsuits and liability costs. Employees who have been harmed at work in an act of violence should receive assistance with any documentation needed to receive necessary health care. Psychological and other supportive therapies should be offered, and the victims should avail themselves of these services.

When a violent event occurs, the organization should take immediate action to prevent recurrence. An investigation should always follow any violent event to determine if new emergency procedures need to be implemented and if any existing policies or procedures need to be changed to protect staff. Any staff member involved in a violent incident should be supported and offered counseling. Care should be taken to determine if the problem may be related to underreporting of warning signs. Staff of the affected areas should be involved with the investigation and should be given as much information as possible to ensure that they know that the safety issue is being addressed. Additional training should be offered. Existing training should be evaluated to determine if it addresses current situations. Advice from safety experts should be sought to ensure that interventions are addressing any problem areas. This will help the organization keep abreast of new strategies for dealing with workplace violence as they develop.

Finally, the success of safety interventions should be regularly evaluated. An evaluation program should examine the reporting system for incidents to determine whether problems exist with not identifying situations because of underreporting. Data related to the frequency and severity of workplace violence and the subsequent interventions should be examined along

Exercise 25-5

You have been asked to help an inner-city hospital. The administration staff has advised you that the current safety plan may not be adequate because several incidents have occurred in the hospital in the past year involving violent attacks on staff members. How would you go about conducting an assessment of the facility? What types of things would you look for? What tools would you use to guide your assessment?

with the outcomes to determine if changes need to be made. Staff surveys before and after implementing safety interventions should be assessed. The question is do they believe the intervention made a difference?

Employees have the right to expect a safe work environment, but they are also expected to participate in active prevention through gaining knowledge of safety policies, participating in training, and reporting potential problems. Through communication and attention to problems, organizations can foster a climate of trust and respect among workers and between employees and management. This helps reduce the potential for toxic work environments that can allow horizontal violence to flourish.


Workplace violence affects us all. Its burden is borne not only by victims of violence but also by their co-workers, their families, their employers, and patients. Although we know that each year workplace violence results nationwide in hundreds of deaths and more than 2 million injuries, it also creates billions of dollars of waste in lost productivity, reduced quality of care, and errors. Our understanding of workplace violence in health care is still in its infancy. Much remains to be done in the area of research, particularly in data collection and interventions for horizontal violence. Without basic information on who is most affected and which prevention measures are effective in what settings, we can expect only limited success in addressing this problem. The first steps have been taken, but a number of key issues have been identified that require future research. All nurses and healthcare leaders need a broader understanding of the scope and impact of workplace violence to reduce the human and financial burden of this significant public health problem.

The Solution

A team was formed that consisted of the director of security; clinical manager; directors of the emergency department, plant operations safety, and risk management; and numerous other stakeholders. We did an analysis of the event and a comprehensive security assessment. One of our major findings was that there were staff panic buttons in the front treatment areas but not in the back “crash” area where the incident occurred. We also realized that the existing panic buttons were near the heads of the beds but needed to be away from the reach of the patient. We made a lot of changes in the physical layout of the emergency department to enhance security, but we realized this was only part of the solution.

Next we devised a method to identify a potentially violent patient and make sure this information was communicated through each patient hand off. Our existing high alert program indicates previously reported and potential risk behaviors of known patients with different levels. Level 4 indicated no issues. Level 3 indicated patients with suspected narcotic-seeking behavior, previous abusive behavior, or other medical conditions that could increase the potential for violent behavior. Level 2 specified patients who had attempted suicide while hospitalized. Level 1 indicated homicidal behavior such as making threats with a weapon or a history of physical assault. The level is noted in the medical record, indicated on the patient’s wristband and on all patient chart labels. Although the emergency department staff was very familiar with the high alert program, we found that this was not the case in the acute care setting.

To ensure that the high alert program was understood throughout the facility, we developed an algorithm that included high alert program levels as well as other prompting questions to identify potential safety threats. If issues are identified, protocols are triggered to ensure appropriate interventions. One intervention is a gray flag, used at the room door to notify staff of the safety risk and to enter only in pairs. The staff knows the meaning of the gray flag; for visitors or others who may ask, the gray flag is to indicate the patient is not to be disturbed. Reduction of disruptions and the pair staff approach decreases the potential for a violent event. The gray flag icon also appears on the bed board in the emergency department with the potentially violent patient’s room highlighted in aqua. This alerts security staff to round more frequently in those areas. This also makes everyone in the department aware of the security risks. Security is now part of hand-off communication, notifying staff when at-risk patients are transferred to any other area in the facility.

We also started communicating our zero tolerance for violence with a poster campaign. Around that same time, a bill was moving through the Texas Legislature aimed at increasing the penalty from a misdemeanor to a felony for anyone who injures an emergency services worker. The bill passed at the end of the session, allowing us to strengthen the message that we will not tolerate injury to our staff.

Lastly, we looked at the support available to staff who were victims of violence by patients. We have psychological services available to help them with any issues they may have as the result of an attack or injury.

We are two years into this process. As we go along we are discovering other ways to improve safety and focus on prevention of violent events.

The ED Staff and Safety Manager

    • Would this be a suitable approach for you? Why?

The Evidence

Workplace violence is recognized as a significant problem within health care, whether the threat comes from within the organization or from the outside. Reviews of nursing literature indicate that violence and incivility in the workplace is a significant reason why nurses leave their jobs and, in some cases, the profession. With continued concern about a nursing shortage and growing awareness that violence in any form impacts the safety and quality of care, nurse leaders need to implement effective intervention programs to foster a safe and civil workplace. Direct care nurses need to have an awareness of how to identify and prevent bullying or lateral aggression so cultures of incivility can be eradicated. The impact of not taking action will be a higher cost of care, greater risk to patients, and potentially a critical decrease in the nursing workforce.

What New Graduates Say

  • I was just starting my residency program and was in that place after you get your license where you realize you know just enough to be dangerous. I was feeling insecure and asked my preceptor lots of questions. Each time she rolled her eyes at me and asked “What do you know?” It made me not want to ask her any questions. I kept wondering what I would do if I really needed help. I made a pledge to always be a friend and support to the new graduates.
  • As a new grad I felt I had to prove myself to fit into the unit where I was first hired. I took on the harder patients and I had to be there earlier and stay later than everyone else. I got really burned out that year. During the course of the year I floated to a different unit and experienced a totally different environment. The nurses were supportive of one another, the manager responded to conflicts and mediated solutions. There was a real sense of teamwork. I am glad to say that is now where I work; I am back to loving my job!
  • I started my healthcare career as an RN in the emergency department. As a new nurse, I observed great differences in how the experienced nursing staff managed difficult patients. Some nurses seemed to be able to manage hostile patients with patience, calmness, and sometimes humor. Other nurses seemed to have great difficulty with patients that would escalate to the point where security needed to be called. I am trying to learn from the seasoned nurses who handle these situations with skill. They used communication and body language to keep the situation under control. The best protection is prevention, or stopping the situation from getting out of control.

Chapter Checklist

This chapter focused on two kinds of workplace violence: physical attacks and bullying. Nursing research indicates violence in any form can drain nurses of their enthusiasm for their work and undermines efforts to create a satisfied workforce. It also impacts the quality of care and patient safety. At a time when we are facing a nursing shortage and skyrocketing healthcare costs, preventing or eliminating violence is paramount. All nurses—leaders, managers, and followers—must be aware of the potential for all forms of violence and strive to not participate in horizontal violence, which weakens us as a profession. The key to preventing violence is to understand the potential and implement interventions to minimize that potential.

  • Defining workplace violence and incivility
  • Scope of the problem
  • The cost of workplace violence
  • Ensuring a safe workplace
  • Making a difference
  • Prevention strategies
    • Types of violence
    • Risk assessment
    • Firing right
  • Horizontal violence: The threat from within
    • Increasing awareness of horizontal violence
    • Education
  • Developing a safety plan
    • Administrative
    • Environmental
    • Interpersonal
    • Understanding the potential for violence
    • Personal safety training
    • After a violent event

Tips for Preventing Workplace Violence

  • Take a self-defense course to help you develop other skills to keep you safe at work and elsewhere.
  • Take advantage of training offered on workplace violence. If training is not offered, ask your employer to consider providing it.
  • Make a personal commitment to not participate in any behaviors that perpetuate horizontal violence.
  • Practice precautionary strategies such as the STAMP assessment.
  • Analyze workplaces for safety risk factors using the checklists provided by OSHA.


Agarwal, R., Sands, D.Z., Diaz-Schneider, J.: Quantifying the economic impact of communication inefficiencies in US Hospitals. 2008, University of Maryland Center for Health Information and Decision Systems, Winter College Park, MD, CHIDS Research Briefing, 3(18).

American Nurses Association: Promoting safe work environments for nurses. From Occupational Safety and Health Administration (OSHA). (2004). Guidelines for preventing workplace violence for health care and social service workers (OSHA Publication No. 3148-01R) 2002, U.S. Department of Labor, Washington, DC,

American Nurses Association: Hostility, abuse and bullying in the workplace. 2010 House of delegates resolution. Bullying and lateral violence examples of bullying behavior pocket card. 2010, Retrieved February 15, 2013, from

American Nurses Association: Nationwide state legislative Agenda: Workplace violence map. 2012, Retrieved February 15, 2013 from

Bureau of Labor Statistics, U.S. Department of Labor: Census of fatal occupational injuries. USDL 12-1888, 2012, Retrieved May 15, 2013, from

Bureau of Labor Statistics, U.S. Department of Labor: Nonfatal occupational injuries and illnesses requiring days away from work, 2011. USDL 12-2204 2012, Retrieved May 15, 2013, from

DeBecker, G.: The gift of fear: Survival signals that protect us from violence. 2000, Little, Brown and Co, New York.

Dellasega, C.: Bullying among nurses. American Journal of Nursing109(1), 2009, 52–58.

Dellasega, C.: When nurses hurt nurses: Recognizing and overcoming the cycle of bullying. 2011, Sigma Theta Tau International, Indiana.

DeVito, J.A.: Essentials of human communication. 6th ed., 2008, Pearson, Allyn and Bacon, Boston, MA.

Farrell, G.: From tall poppies to squashed weeds: Why don’t nurses pull together more?. Journal of Advanced Nursing35(1), 2001, 26–33.

Freire, P.: Pedaogogy of the oppressed. 30th ed., 2003, International Publishing Group, New York, NY.

Gacki-Smith, J., Juarez, A.M., Boyett, L.: Violence against nurses working in U.S. emergency departments. The Journal of Nursing Administration39(7/8), 2009, 340–349.

Gates, D.M., Gillespie, G.L., Succop, P.: Violence against nurses and its impact on stress and productivity. Nursing Economics29(2), 2011, 59–67.

Gallant-Roman, M.: Strategies and tools to reduce workplace violence. American Association of Occupational Health Nurses56(11), 2008, 449–454.

Griffin, M.: Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal of Continuing Education in Nursing35(6), 2004, 257–263.

Hartley, D., Ridenour, M.: Workplace violence in the healthcare setting. 2011, September 13, Medscape, Retrieved February 15, 2013 from

Hartley, D., Ridenour, M., Craine, J., Costa, B.: Workplace violence prevention for healthcare workers: An online course. Rehabilitation Nursing37(4), 2012, 202–206.

Holloway, L.E., Kusy, M.E.: Disruptive and toxic behaviors in healthcare: Zero tolerance, the bottom line, and what to do about it. Medical Practice Management25(6), 2010, May/June, 335–340.

Hutchinson, M., Vickers, M., Jackson, D., Wilkes, L.: Workplace bullying in nursing: Towards a more critical organizational perspective. Nursing Inquiry15, 2006, 118–126.

Iowa Injury Prevention Research Center (IIPRC): Workplace violence: A report to the nation. February 2001, University of Iowa—Iowa City, Retrieved May 15, 2013, from

Johansen, M.L.: Keeping the peace: Conflict management strategies for nurse managers. Nursing Management43(2), 2012, 50–54.

Johnson, S.: Workplace bullying: Concerns for nurse leaders. Journal of Nursing Administration39(2), 2009, 84–90.

Lewis, P.S., Malecha, A.: The impact of workplace incivility on the work environment, manager skill and productivity. The Journal of Nursing Administration41(1), 2011, 41–47.

Longo, J.: Leveling horizontal violence. Nursing Management38(3), 2007, 34–37, 50–51.

Luck, L., Jackson, D., Usher, K.: STAMP: Components of observable behavior that indicate potential for patient violence in emergency departments. Journal of Advanced Nursing59(1), March 2007, 11–19.

Maslow, A.H.: A theory of human motivation. Psychological Review50(4), 1943, 370–396.

Monahan, J.: Predicting violent behavior: An assessment of clinical techniques. 1981, Sage, Beverly Hills, CA.

Occupational Safety and Health Administration (OSHA): Guidelines for preventing workplace violence for health care and social service workers. (OSHA Publication No. 3148-01R) 2004, U.S. Department of Labor, Washington, DC.

Occupational Safety & Health Act (OSH Act): Public Law 91-596, 84 STAT. 1590, Section 5. 91st Congress, S.2193, December 29, 1970. as amended through January 1, 2004 1970.

Occupational Safety and Health Administration (OSHA): Workplace violence. 2013, Retrieved from

Paludi, M., Nydegger, R., Paludi, C.: Understanding workplace violence: A guide for managers and employees. 2006, Praeger, Westport, Connecticut.

Papa, A., Venella, J.: Workplace violence in healthcare: Strategies for advocacy. The Online Journal of Issues in Nursing18(1), 2013, 1–10.

Pearson, C., Porath, C.: The cost of bad behavior: How incivility is damaging your business and what to do about it. 2009, Portfolio, London.

Porto, G., Lauve, R.: Disruptive clinical behavior: A persistent threat to patient safety. 2006, July/August, Patient Safety and Quality Healthcare, Retrieved February 15, 2013, from

Purpora, C., Blegen, M.A.: Horizontal violence and the quality and safety of patient care: A conceptual model. Nursing Research and Practice. 2012, 2012:306948.

Reason, J.: Human error: Models and management. British Medical Journal320(7237), 2000, 768–770.

Roberts, S.J., Demarco, R., Griffin, M.: The effect of oppressed group behaviors on the culture of the nursing workplace: A review of the evidence and interventions for change. Journal of Nursing Management17, 2009, 288–293.

Rosenstein, A.H.: Measuring and managing the economic impact of disruptive behaviors in the hospital. Journal of Healthcare Risk Management30(2), 2010, 20–26.

Shields, M., Wilkins, K.: Factors related to on-the-job abuse of nurses by patients. Health Report20(7), 2009, 7–19.

Stokowski, L.A.: Violence: Not in my job description. 2010, August 23, Medscape, Retrieved February 15, 2013, from

The Joint Commission (TJC): Behaviors that undermine a culture of safety. Sentinel Event Alert. (40), 2008, Retrieved May 15, 2013, from

The Joint Commission (TJC): Preventing violence in the health care setting. Sentinel Event Alert. (45), 2010, Retrieved May 15, 2013, from

Winfeld, L.: Training tough topics. 2001, American Management Association, New York.

Woelfle, C., McCaffrey, R.: Nurse on nurse. Nursing Forum42(3), 2007, 123–131.

Suggested Readings



My Homework Nest
Calculate your paper price
Pages (550 words)
Approximate price: -