I N F OCUS JOGNN CNE and Continuing Nursing Education (CNE) Credit in the Workplace and Nurses ’ A total of 2 contact hours may be earned as CNE credit for reading “Incivility and Bullying in the Workplace and Nurses’ Shame Responses Responses,” and for completing an online post-test and evaluation. Dianne M. Felblinger1 AWHONN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. ABSTRACT AWHONN also holds California and Incivility and bullying in the workplace are intimidating forces that result in shame responses and threaten the well- Alabama BRN numbers: California being of nurses. Some nurses are accustomed to tolerating behaviors that are outside the realm of considerate CNE provider #CEP580 and Alabama #ABNP0058. conduct and are unaware that they are doing so. These behaviors affect the organizational climate, and their http://JournalsCNE.awhonn.org negative effects multiply if left unchecked. Interventions for incivility and bullying behaviors are needed at both individual and administrative levels. JOGNN, 37, 234-242; 2008. DOI: 10.1111/j.1552-6909.2008.00227.x Accepted October 2007

iolence … begins long before fi sts fl y or lethal poll by U.S. News and World Report, 89% of Ameri- Correspondence V weapons extinguish lives. Where resentment and cans identifi ed incivility as a serious social problem Dianne M. Felblinger, EdD, aggression routinely displace cooperation and commu- and 78% agreed that it had worsened in the past 10 MSN, WHNP-C, CNS, RN, College of Nursing, University nication, violence has occurred. years ( Marks, 1996). Incivility continues to invade the of Cincinnati, P.O. Box workplace regardless of setting ( Hutton, 2006 ), and — Bernice Fields, Arbitrator (Namie, 2003). 210038, Cincinnati, the psychological of nurses at work is an OH 45221-0038. ongoing concern. [email protected] Incivility, bullying, and subsequent shame responses are formidable forces that threaten the well-being Incivility and bullying fl ourish in unsupportive work 1 EdD, MSN, WHNP-C, CNS, RN, associate professor, of both nurses and patients. This article provides a groups that normalize competitive and abusive behav- women ’ s health nurse description of the disruptive behaviors associated with iors. Nurses work in groups; they negotiate complex in- practitioner, College of incivility and bullying and their subsequent adverse terpersonal relationships in highly politicized settings Nursing, University of clinical outcomes. A description of incivility and bullying with economic restrictions. As the nursing shortage per- Cincinnati, OH in the workplace is followed by a discussion of nurses ’ sists, nurses take on increasing responsibility and are Dr. Felblinger reports receiving risk for shame responses to these negative behaviors. expected to provide leadership in situations that are of- consulting fees from Procter Implications for nursing practice are presented and ten unpredictable and chaotic. Under these circum- and Gamble, Inc. She disclosed stances, many nurses encounter verbal when no other potential confl icts of nursing interventions proposed. interest relevant to this article. coworkers ineffectively cope with diffi cult work-related challenges by lashing out at each other ( Taylor, 2003 ). Keywords Prevalence and Effects In some situations, nurses engage in destructive nurse- incivility to-nurse or “ horizontal ” hostility, through actions such bullying of Disruptive Behaviors disruptive behaviors as critical commentary, career sabotage, and shame in the Workplace ( Thomas, 2003 ). violence Since the 1990s, recognition of negative workplace workplace violence harassment behaviors has increased (Lutgen-Sandvik, Tracy, & Prevalence of Abusive Behavior Alberts, 2007). These disruptive behaviors include use Previous research indicates that coworker incivility and of verbally abusive language, tactics, sex- bullying are more prevalent than blatant and overt types ual comments, racial slurs, and ethnic jokes. Additional of violence such as battery or homicide ( Baron & disruptive behaviors include shaming or criticizing Neuman, 1996, 1998 ). is described as a team members in front of others; threatening team common experience among health care providers, with a members with retribution, litigation, violence, or job prevalence of 80% to 90% ( Sofi eld & Salmond, 2003). loss; throwing instruments, and hurling charts or other Bullying prevalence rates have been reported between objects ( Pfi fferling, 2003; Porto & Lauve, 2006 ). In a 1% and 4% ( Einarsen, 2000).

234 © 2008, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org Felblinger, D. M. I N F OCUS CNE http://JournalsCNE.awhonn.org Most verbal abuse in cases involving nurses is insti- gated by physicians; yet, nurse-instigated instances More than half of nurses surveyed by Joint Commission on of verbal abuse are the second most common type Accreditation of Healthcare Organizations reported that they ( Johnson, DeMass, & Marker-Elder, 2007 ). In 2004, had been subject to verbal abuse. more than half of nurses surveyed by the Joint Commis- sion on Accreditation of Healthcare Organizations (JCAHO) reported that they had been subject to verbal intent to harm the target, in violation of workplace norms abuse, and more than 90% had witnessed disruptive for mutual respect. ” Pearson, Andersson, and Wegner behavior (JCAHO, 2002). In a 2005 hospital survey, (2001) further characterized as in- 72% of nurse respondents reported witnessing disrup- clusive of “ rude and discourteous behavior, displaying tive behavior perpetrated by another nurse (Rosenstein a lack of regard for others. ” & O’ Daniel, 2005 ). This survey defi ned disruptive be- Incivility includes both subtle and obvious levels of havior as any inappropriate behavior, confrontation, or rude and discourteous behavior, exclusion from impor- confl ict ranging from verbal abuse to physical and sex- tant work activities, taking credit for another’ s work, ual harassment. withholding important information, yelling, screaming, In a recent study, intimidating behavior demonstrated verbal attacks, and expression of negative verbal com- by professionals in labor and delivery units included an- ments in front of others. During life-threatening situa- gry outbursts; ; verbal attacks; physical threats tions, women ’s health nurses and physicians may or aggressive physical contact; violation of policies; verbally criticize or team members for unfavor- sexual harassment; idiosyncratic, inconsistent, or pas- able outcomes. Other common examples of incivility sive aggressive orders; derogatory comments about include berating colleagues or workers in e-mail com- the organization; and disruption of smooth function of munications; exhibiting emotional tirades, angry out- the health care team ( Veltman, 2007 ). Although physi- bursts, or overt temper tantrums; interrupting others; cians displayed the largest incidence of disruptive be- and disrupting meetings. Individuals may be self- havior (in 69.1% of cases) nurses’ behavior was serving and unable to empathize, constantly negative, disruptive in the remaining 30.9%. condescending, and refusing to work collaboratively with administrators or peers. Gossiping and spreading Risks to Patients rumors that damage a coworker’ s reputation, name- When incivility and bullying are sustained through dis- calling, and discounting input from others at any ruptive behaviors in the workplace, nurses suffer and organizational level also contribute to a hostile work patient care is adversely affected. Twenty-fi ve percent environment ( Table 1 ). of health care workers saw a strong link between dis- Keashly (2001) further postulated that the most fre- ruptive behaviors and patient mortality, and as many as quent form of workplace aggression is emotional and 53% and 75% of health care providers saw a strong link psychological in nature and stated that behaviors be- between disruptive behavior and adverse clinical out- come increasingly improper when they are repetitive, comes, such as patient safety, errors, adverse events, result in harm or injury, and are experienced as a lack quality of care, and patient satisfaction ( Rosenstein & of recognition of the individual ’ s integrity. Keashly ’s fo- O ’ Daniel, 2005 ). In a study by the Institute for Safe Med- cus on the meaning of the behaviors for the target pro- ication Practices (ISMP, 2004), 49% or almost half of all vides an enriched perspective of the defi nition of respondents stated that intimidation interfered with the incivility. way they clarifi ed medication orders or dispensed a product or led them to administer a medication despite concerns. Incivility as a Precursor of Bullying Although incivility is considered professional miscon- duct, a breech of etiquette, and representative of moral Incivility decay, the question of intent to harm distinguishes inci- Characteristics of Incivility vility from bullying or other forms of aggressive behav- In order to eradicate incivility and bullying behaviors, ior. Namie (2003b) considered incivility a type of nurses and administrators must fi rst understand fully organizational disruption and rated it at a level of 1 to 3 what they are. The literature provides various defi nitions on a 10-point continuum, with bullying rated as 4 to 9 of incivility. In general, incivility is seen as a form of and battery or homicide rated as a 10. Incivility has psychological harassment and emotional aggression been seen as a precursor to harassment, aggression, that violate the ideal workplace norm of mutual respect. and physical assault (MacKinnon, 1994). However, the Andersson and Pearson (1999) defi ned workplace inci- relationship of incivility to bullying remains under vility as “ low-intensity deviant behavior with ambiguous investigation.

JOGNN 2008; Vol. 37, Issue 2 235 I N F OCUS Incivility, Bullying, and Shame Responses CNE http://JournalsCNE.awhonn.org natal nurses to provide safe care with inadequate and Table 1 : Common Examples of Workplace Incivility unsafe levels of staffi ng. Exclusion from important work activities Yelling, screaming, verbal attacks Einarsen (2000) identifi ed predatory bullying as the Taking credit for another ’ s work Emotional tirades, angry outbursts over another individual. Zapf and Gross Refusing to work collaboratively Overt temper tantrums (2001) , building on work from Einarsen, Einarsen and Interrupting others Gossiping Skogstad (1996), and Leymann (1996), strictly defi ned Disrupting meetings Name-calling bullying as occurring when someone is “ harassed, of- Discounting input from others Condescending speech, rudeness fended, socially excluded, or has to carry out humiliat- Berating workers on e-mail Spreading rumors ing tasks and if the person concerned is in an inferior position. ” To consider a behavior as bullying, it must oc- Failing to share credit for collaborative work Inability to empathize cur repeatedly (at least twice a week or more) and for a Withholding important information Damaging coworker’ s reputation long time (at least 6 months or more) in situations where targets fi nd it diffi cult to defend against and stop the abuse (Lutgen-Sandvik et al., 2006). A single event is Bullying not bullying, nor is an event categorized as bullying if two equally strong parties are in confl ict (Zapf & Characteristics of Bullying Gross). is a form of aggression at work ( Neuman & Baron, 2005) that goes beyond incivility. Bullying, more than incivility, involves systematic ha- Bullying is a more deliberate and repetitive form of inter- rassment for a long period of time and the instigator’ s personal behavior that adversely affects the health or desire to control the target. This obsession with control the fi nancial well-being of the targeted person. Work- drives the instigator’ s actions and invokes psychologi- place bullying consists of recurrent and persistent neg- cal pain on the part of the target. Targets of workplace ative actions toward one or more individual(s), which bullying endure their pain for an average of 22 months if involve a perceived power imbalance and create a hos- they are unwilling or unable to react assertively to un- tile work environment (Salin, 2003 ). Bullying is a form of wanted aggression (Namie, 2003). Bullying, similar to interpersonal mistreatment that escalates the intensity intimate partner violence, escalates when the target fi - of verbal assault, directs attention and energy away nally decides to assert independence, moves ahead in from the job, and may subsequently render the targeted the corporate environment, or begins to set limits on the nurse at risk for unsafe clinical performance (ISMP, instigator ’ s behavior. As the target becomes more inde- 2004). Intimidating workplace behavior can include pendent, the instigator asserts more control. With in- threats to professional status, threats to personal stand- creased instigator exertion of “ power over,” the target ing, isolation, overwork, and destabilization (Rayner & diverts emotional energy away from work-related re- Hoel, 1997 ). sponsibilities and focuses this energy on coping with the situation. As the target is victimized by continued Bullying is persistent and has detrimental or negative bullying and controlling behaviors, self-blame develops. effects on the victim (Cusak, 2000; Quine, 1999; Randall, Internalization of this blame, self-reproach, and self- 1997). Bullying, or “ ” as it is called in many recrimination enables revictimization of the target. While Continental European countries, is defi ned by Namie the target is preoccupied with self-blame, the instiga- (2003) as a “ status-blind interpersonal hostility that tor ’ s behaviors go unimpeded. Rude and discourteous is deliberate, repeated and suffi ciently severe as to behaviors are often ignored or minimized by manage- harm the targeted person’ s health or economic status.” ment despite the repetitive and aggressive nature of Randall described bullying as “ the aggressive behavior the offense. These recurring sublethal behaviors arising from the deliberate intent to cause physical or may render the targeted nurse professionally unsafe psychological harm.” (ISMP, 2004). Power and Control Are Key to Bullying Both stress theory and confl ict theory provide a context Effects of Bullying on the Target in which to understand bullying. In the context of stress Bullying causes serious health problems in the target of theory, bullying is perceived as a severe form of social the bullying (Einarsen, 2000 ). Many targets of bullying stress at work. In confl ict theory, bullying signifi es an suffer from post-traumatic stress disorder and symp- unsolved social confl ict that has reached a particularly toms of low self-esteem, anxiety, sleep disturbance, re- high level of escalation with an increased imbalance of current nightmares, somatic problems, concentration power ( Zapf & Gross, 2001). An example of this type of diffi culties, irritability, , and feelings of self- “ power-over ” situation occurs when hospital administra- hatred (Mikkelsen & Einarsen, 2002). Some targets tors continually expect obstetric, gynecologic, and neo- feel that their health is permanently impaired and

236 JOGNN, 37, 234-242; 2008. DOI: 10.1111/j.1552-6909.2008.00227.x http://jognn.awhonn.org Felblinger, D. M. I N F OCUS CNE http://JournalsCNE.awhonn.org they will never function normally or resume work again dren learn to develop increasing independence in a ( Leymann, 1996 ). Bullying results in the loss of bright, supportive, nonshaming atmosphere, and this need for talented, and motivated women’ s health and neonatal supportive relationships continues throughout adult life. nurses. Since mistreatment of nurses in the workplace It follows that adult nurses would also thrive in an envi- may result in adverse clinical and personal outcomes, ronment where they are not constantly criticized, where there is a need to develop a deeper understanding of incivility and bullying are not tolerated, and where sham- the nurses’ reaction to nonphysical types of violence ing is not a norm of behavior. such as incivility and bullying. The link between incivil- Kohut (1971) also discussed the concept of evolution of ity, bullying, and shame is worthy of discussion and fur- the self. Kohut saw the condition of self developing ther investigation. more positively and “ unfolding in an affi rming environ- ment. ” The work of both Erikson and Kohut emphasizes Shame the importance of development in a supportive environ- ment with norms that do not tolerate a hostile environ- Psychological effects of bullying may include a shame ment of incivility and bullying. response that results in an “attack-self ” phenomenon. When nurses are fi rst victimized by emotionally abu- Kaufman (1996) described shame as “ an affective sive behaviors, their immediate response may be one experience that violates both interpersonal trust and in- of shame and . The nurses ’ initial shame re- ternal security. ” Kaufman believed that everyone expe- sponse to violence can elicit an attack-self coping re- riences self-doubt, looks internally to fi nd the source of action that is characterized by inner-directed anger discomfort, and the self for any inadequacies. ( Nathanson, 1992 ). When nurses attack themselves This self-blame leads to insecurities about one’ s iden- and direct their anger inward, they once again tity. “ Where we once stood secure in our personhood, become victimized, which is known as revictimization now we feel a mounting inner anguish, a sickness of the ( Figure 1 ). Concurrent with eradication of incivility soul ” ( Kaufman, 1985 ). When nurses become targets of and bullying, nurses may also benefi t from learning incivility or bullying, look internally, blame themselves to manage their own shame response to these nega- for the situation, and mobilize an attack-self coping tive behaviors. Eliminating the shame response may mode, shame may be imminent. facilitate the avoidance of revictimization and leave nurses free to invest more psychological energy in Effects of Shame Responses safe patient care. In situations where incivility or bullying, or both occur, the targeted nurse may not recognize or be able to la- To grasp the magnitude of the shaming process and its bel the subtle or overt aggression and shaming experi- proposed relationship to coworker violence, it is helpful ence. The nurse consequently develops a self-blaming to fi rst understand that everyone experiences shame. attitude, silently endures the situation, and may sub- The phenomenon of shame has been documented in sequently exhibit unsafe clinical behaviors in an intimi- the literature since the late 1800s. Freud wrote that dating work environment (ISMP, 2004). Mounting shame is an affective response to exposure and a com- shame in this negative situation often leads to anger ponent of intrapsychic confl ict. Freud (1892-1899) be- ( Pastor, 1995). As the nurse experiences diffi culty lieved that people “ keep back part of them they ought to discharging this anger appropriately, there is a propen- tell — things that are perfectly well known to them — be- sity for emotional self-blame in conjunction with an in- cause they have not got over their feeling of timidity and ternalized, attack-self mode of coping. According to shame. ” This historic perspective is certainly congruent Lewis (1971), the experience of shame is a direct pre- with the behavior of the bully’ s target, who “ keeps back ” cursor to a negative self-evaluation on the part of the and endures the pain for an average of almost 2 years target. (Namie, 2003). Tomkins (1963), an experimental psychologist, pub- Shame Impairs Development lished much of the seminal work about Affect Theory of a Healthy Self and shame. Tomkins viewed shame as an affect with In the 1960s, Erikson investigated shame from a devel- “ relatively high toxicity” that leaves a person emotionally opmental perspective. Erikson proposed eight psycho- “ defeated, alienated and lacking in dignity. ” Tomkins social stages during the human life span. Autonomy believed that shame occurs when the positive affects of versus Shame and Doubt is the second stage and oc- excitement and enjoyment are blocked and reduced. curs initially at ages 1 to 3 of life. During this stage, chil- For example, incivility and bullying behaviors in the dren who are consistently criticized for expressions of nursing workplace may act as impediments to feelings autonomy or for lack of control develop a sense of of interest-excitement or enjoyment-joy and invoke a shame about themselves and doubt their abilities. Chil- shame response in the individual. When nurses are the

JOGNN 2008; Vol. 37, Issue 2 237 I N F OCUS Incivility, Bullying, and Shame Responses CNE http://JournalsCNE.awhonn.org self-deceptive patterns of ignoring, disavowing, or When nurses are the targets of abusive behaviors, their distracting oneself from the painful situation. The work-related interest and enjoyment dissipate and their safe clinical defensive pattern of attack-others involves put-down, performance may suffer. ridicule, contempt, and character assassination. The targeted nurse may outwardly direct this defensive targets of abusive behaviors, their work-related interest behavior toward nurse peers or patients. A targeted and enjoyment dissipate and their safe clinical perfor- nurse who exhibits this attack-others response is at mance may suffer. For women ’ s health and neonatal risk for the adverse consequences of confl ict escala- nurses who take pride in their professional competence, tion, one of which is further bullying or actual physical this adverse situation may result in overwhelming violence. Becoming a bully creates even more dan- shame. gerous terrain (Nathanson).

Nathanson (1992) built on Tomkins work and described For nurses who move into an attack-self mode, the the shame affect as “ a highly painful mechanism that self-mantra seems to be “ do unto yourself what you fear operates to pull the organism away from whatever might others may do to you ” ( Nathanson, 1992, p. 329). Prob- interest it and make it content. Shame is painful in lems occur when the process of attacking the self feels direct proportion to the degree of positive affect it limits ” better than having someone else do it. Those who feel (p. 138). This painful experience leads to decreased helpless in the face of bullying and incivility are most contentment and increased shame. In the work environ- likely to use attack-self scripts to modulate shame. This ment, “ shame is by far the more commanding affective attack-self tactic associated with inner-directed anger is experience in the life of mature, successful people. It is a revictimization of the nurse. the fall from grace, the loss of face, the forfeiture of social position accompanying exposure, that we fear Interventions are needed to prevent the initial incivility most ” (p. 144). and bullying behaviors that precede unsafe care and also activate an ensuing cascade of shame and anger, Nurses’ Responses to Shaming leading to destructive, attack-self behaviors in the When shame is triggered, individuals respond in nursing workplace. When nurses realize that they are one of four defensive patterns: withdrawal, avoidance, experiencing shame as a result of work place abuse, attack-others, and attack-self (Nathanson, 1992). they are in a prime position to obtain assistance to stop Withdrawal into the self provides respite from the the abuse, avoid shame and revictimization, learn new shame experience and is considered a healthy re- coping skills, prevent unsafe clinical behaviors, and sponse because it provides safety from any further confi dently confront similar malicious situations. shame that might occur in the presence of others (Nathanson). An avoidance reaction to shame occurs Nursing Implications when no portion of the shame experience is emotion- Interventions for incivility and bullying behaviors are ally tolerable to the target. Avoidance involves the needed at both individual and administrative levels. Depending on the nurse’ s background and tempera- ment, the parameters of acceptable, respectful behav- ior may require defi nition. Some nurses are unfortunately accustomed to tolerating behaviors that are outside the realm of considerate conduct and are unaware that Incivility and bullying victimization they are doing so. Education is needed at the individual and the unit level in an effort to raise the awareness of everyone involved. Once the boundaries of appropriate interpersonal behaviors are identifi ed and internalized, Hostile Shame workplace nurses and administrators can begin the serious busi- ness of creating a respectful work environment.

The American Association of Critical Care Nurses (AACN) has developed a powerful position statement Anger that supports zero tolerance for abuse. This statement Revictimization Self-blame Self-attack addresses the issue of intimidation and verbal abuse by peers, colleagues, and coworkers as a barrier to the provision of safe, quality care (AACN, 2004). To encour- age a culture of safety and excellence, the AACN Figure 1 . Victimization and revictimization in workplace violence. has also published six essential, evidence-based, and

238 JOGNN, 37, 234-242; 2008. DOI: 10.1111/j.1552-6909.2008.00227.x http://jognn.awhonn.org Felblinger, D. M. I N F OCUS CNE http://JournalsCNE.awhonn.org relationship-centered standards for establishing and sustaining healthy work environments ( Table 2 ). In this Once the boundaries of appropriate interpersonal document, AACN calls for the development of commu- behaviors are identifi ed and internalized, nurses and administrators nication skills equal to the desired level of clinical prac- can begin to create a respectful work environment. tice skills (AACN, 2005). As communication skills increase, the level of incivility and bullying in the work- place may decrease. research needs to draw on appropriate theoretical frameworks, address the contexts in which incivility or Efforts such as the AACN Standards and Zero Toler- bullying occurs, and employ strong evaluation research ance statement help eliminate incivility, bullying, and designs, including attention to process and outcome the associated disruptive behaviors. The goal is the de- measures (Runyan, Zakocs, & Zwerling, 2001 ). velopment of an emotionally safe work environment that empowers nurses and ultimately fosters the well-being Interventions that create a positive organizational envi- of their patients. Implementation of AACN standards ronment, retain nurses, and decrease interpersonal and a zero tolerance of abuse policy are two concrete mistreatment are essential. When administrators inten- steps institutions can take to create and sustain a tionally or inadvertently ignore the adverse effects of in- healthy work environment. civility and bullying, employees respond with increased absenteeism (Barling & Phillips, 1993), increased turn- Porto stresses the need for strong policy statements over ( Rosenstein & O’ Daniel, 2005 ), and heightened and a strong code of conduct, in addition to clear re- turnover intentions ( Maxfi eld, Grenny, McMillan, porting mechanisms and instant access to senior lead- Patterson, & Switzler, 2005). Reduced commitment to ers who are empowered to take immediate action (Joint the organization also occurs (Barling & Phillips; Commission Resources, 2006 ). Establishment of an Leather, Beale, Lawrence, & Dickson, 1997 ). emotionally safe workplace benefi ts both nurses and their patients. As employees react to interpersonal mistreatment with a shame response and gravitate toward an attack-self Although empirical evidence has linked a range of un- mode of coping, they begin to distrust and resent the just, harassing, verbally abusive, or psychologically ag- unresponsive organizational hierarchy. Administrative gressive workplace behaviors with adverse job-related indifference and insensitivity to negative nuances, in consequences in individual targets (Cortina, Magley, turn, stifl e employee participation, innovation, and cre- Williams, & Langhout, 2001), little organizational re- ativity (Pearson et al., 2001). In a world where business search has tested interventions to reduce coworker mis- survival is based upon effi ciency, productivity, and in- treatment in the forms of incivility and bullying. The novation, it is increasingly clear that the development of presence of these behaviors affects the organizational a safe workplace, devoid of interpersonal mistreatment, climate, and the negative effects multiply if left un- is both desirable and necessary. checked. Often the target is silenced and the instigator of the mistreatment avoids detection. Interventions need to be focused on altering the rewards and sanctions Conclusions that instigators experience as part of the workplace cul- Fostering a workplace in which nurses feel safe from ture (Namie, 2003a). intimidation directs valuable human energy toward at- The lack of intervention research to assess administra- tainment of organizational goals and contributes to in- tive and behavioral measures and address interpersonal creased productivity. Insights into the relationship mistreatment represents a signifi cant gap. Intervention between incivility, bullying, and shame can help nurses

Table 2 : AACN Standards for Establishing and Sustaining Healthy Work Environments Topic Standard Skilled communication Nurses must be as effi cient in communication skills as they are in clinical skills True collaboration Nurses must be relentless in pursuing and fostering true collaboration Effective decision making Nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading organizational operations Appropriate staffi ng Staffi ng must ensure the effective match between patient needs and nurse competencies Meaningful recognition Nurses must be recognized and recognize others for the value each brings to the work of the organization Authentic leadership Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement

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240 JOGNN, 37, 234-242; 2008. DOI: 10.1111/j.1552-6909.2008.00227.x http://jognn.awhonn.org Felblinger, D. M. I N F OCUS CNE http://JournalsCNE.awhonn.org Quine , L . ( 1999 ). Workplace bullying in NHS community trust staff Post-Test Questions questionnaire survey . British Medical Journal , 318 , 228 - 232 . Randall , P . ( 1997 ). Adult bullying: Perpetrators and victims . London : 1. Since the 1990s recognition of negative work- Routledge . place behaviors has Rayner, C. , & Hoel , H . ( 1997 ). A summary review of literature relating a. decreased to workplace bullying . Journal of Community Applied Social b. increased Psychology , 7 , 181 - 191 . Rosenstein , A. H. , & O ’ Daniel , M . ( 2005 ). Disruptive behavior and c. remained the same clinical outcomes: Perceptions of nurses and physicians . 2. Disruptive behavior associated with incivility is American Journal of Nursing , 105 , 54 - 64 . present when health care providers Runyan , C. W. , Zakocs , R. C. , & Zwerling , C . ( 2001 ). Administrative a. address each other with rude, condescend- and behavioral interventions for workplace violence preven- ing speech tion . American Journal of Preventive Medicine , 18 , 116 - 127 . b. deliberately intend to harm a co-worker Salin , D . ( 2003 ). Ways of explaining workplace bullying: A review of , motivating, and precipitating structures and pro- c. exert power over other workers who have cesses in the work environment . Human Relations , 56 , 1213 - less formal authority 1232 . 3. Incivility and bullying behaviors fl ourish in Sofi eld , L. , & Salmond , S. W . ( 2003 ). Workplace violence: A focus on a. competitive groups verbal abuse and intent to leave the organization . Orthopaedic b. emergency situations Nursing , 22 , 274 - 283 . c. supportive work groups Taylor , B . ( 2003 ). Identifying and reducing nurse-nurse horizontal vio- lence and bullying through refl ective practice and action re- 4. Nurses who engage in horizontal hostility search in an Australian hospital . In M. Habermann & L. R. Uys a. attempt to thwart hospital polices and ( Eds .), Violence in nursing ( pp . 177 - 197 ). Frankfurt am Main, procedures Germany : Peter Lang . b. do not speak up when an administrator Thomas , H. E . ( 1995 ). Experiencing a shame response as a precursor makes sexual comments to violence . Bulletin of the American Academy of Psychiatric c. sabotage other nurses’ careers through the Law , 23 , 587 - 593 . Thomas , S. P . ( 2003 ). ‘ Horizontal hostility’ : Nurses against themselves: use of critical commentary How to resolve this threat to retention . American Journal of 5. More than half of nurses surveyed by the Nursing , 103 , 87 - 91 . Joint Commission on Accreditation of Health- Tomkins , S . ( 1963 ). Affect-imagery-consciousness ( Vols. 1-3 ). New care Organizations reported that they had York : Springer . experienced Veltman , L. L . ( 2007 ). Disruptive behavior in obstetrics: A hidden a. aggressive physical contact threat to patient safety [Electronic version] . American Journal of Obstetrics & Gynecology , 196 , 587e1 - 587e5 . Retrieved b. threats of job loss February 2, 2008, from www.ajog.org c. verbal abuse Zapf , D. , & Gross , C . ( 2001 ). Confl ict escalation and coping with 6. Between 53% to 75% of health care workers workplace bullying: A replication and extension . European surveyed saw a strong link between disruptive Journal of Work and Organizational Psychology , 10 , behaviors and 497 - 522 . a. job satisfaction b. patient mortality c. patient safety Continuing Nursing Education (CNE) Credit 7. In a study by the Institute of Safe Medication Practices almost half of respondents reported To take the test and complete the evaluation, that intimidation please visit http://JournalsCNE.awhonn.org. Certifi cates of completion will be issued on a. led them to administer a medicine despite receipt of the completed evaluation form, concerns application and processing fees. Note: AWHONN b. rarely occurred on their own clinical unit contact hour credit does not imply approval or c. stimulated nurse cohesiveness and endorsement of any product or program. collaboration

Objectives 8. Bullying is present when health care providers After reading this article the learner will be able a. direct occasional negative behavior toward to: equally strong co-workers 1. Identify disruptive behaviors associated with b. systematically and repeatedly harass and at- incivility and bullying. tempt to control co-workers 2. Describe adverse outcomes of disruptive c. take credit for the work of others during an behaviors associated with incivility and annual evaluation bullying. 3. Identify standards that help to create and 9. Nurses who are the targets of bullying behaviors sustain a healthy work environment. may develop

JOGNN 2008; Vol. 37, Issue 2 241 I N F OCUS Incivility, Bullying, and Shame Responses CNE http://JournalsCNE.awhonn.org a. increased focus on safe patient care a. defi ne appropriate interpersonal boundaries b. obsessive-compulsive behavior b. develop techniques for counter-attacking c. post traumatic stress disorder abusers. 10. Nurses who are targets of bullying behaviors c. learn how to ignore persistent bullying may endure the pain for an average of almost 14. AACN Standards for Establishing and Sustain- a. 6 months ing Healthy Work Environments state b. 1 year a. nurses must be as effi cient in communication c. 2 years skills as they are in clinical skills 11. Nurses who experience a shame response to b. nurses must be rated by the value each bullying have an initial tendency to brings to the work organization a. blame others for the situation c. nurses must recognize that some abuse is b. blame themselves for the situation an acceptable outcome of interdisciplinary c. talk to administrators about the bullying and collaboration subsequent shame 15. Development of an emotionally safe work envi- 12. The healthiest defensive responsive response to ronment that empowers nurses requires shame is a. delineation of specifi c abusive behaviors that a. attacking others are acceptable under stress b. avoidance b. implementation of a zero tolerance of abuse c. withdrawal policy 13. To achieve a respectful work environment, one c. further research to determine if abusive be- of the fi rst steps for nurses and administrators haviors foster job-related consequences in is to individuals.

242 JOGNN, 37, 234-242; 2008. DOI: 10.1111/j.1552-6909.2008.00227.x http://jognn.awhonn.org