In the United States, healthcare facilities operate 24/7/365 days a year with a nursing workforce that all too frequently feel the physical and emotional impact of delivering care. Leaders function against a backdrop of heightened competition for limited resources while attempting to attenuate stress on the system imposed by risk factors such as workplace violence and bullying, which put nurses in harm's way but also impede nurses' ability to provide high-quality, compassionate, and safe care. At the 2018 American Academy of Nursing (AAN) conference, a policy dialogue was convened on “The Quadruple Aim” focused on improving healthcare work environments by addressing stressors like violence and bullying. This article encapsulates the AAN discussion and provides strategies for reducing risk. In addition, the article acts as a call to action for nursing leadership to consider as they continue to work to create healthful and safe work environments.
Delivering high-quality care can be challenging owing to the complex and often turbulent nature of healthcare work environments. According to the Triple Aim, a frequently used framework to optimize health system performance, delivering high-value care is centered around simultaneously improving the health of populations, enhancing the patient experience, and reducing the cost of care.1 In 2014, the Triple Aim was expanded and renamed the Quadruple Aim to include staff well-being.2
In 2015, the American Association of Critical Care Nurses (AACN) conducted a public forum campaign to identify aspects of nurses' work environments inhibiting optimal patient care (C. Barden, oral communication, September 11, 2019). The Barriers to Practice Assessment identified 5 main themes contributing to workplace stressors: 1) staff shortages and higher workloads; 2) government regulations and hospital requirements; 3) disrespectful behaviors and unrealistic expectations of patients and their families; 4) lack of authentic leadership within practice environments; and 5) hostile workplace culture (C. Barden, oral communication, September 11, 2019). These stressors are known to compromise nurses' job satisfaction and engagement, increase role conflict, lead to friction with leadership, and promote poor relationships between coworkers.3-5 Workplace stress is further amplified by individual's predisposing factors and the general emotional intensity of clinical work.3,4
As multiple stressors occur, the negative consequences can impact care quality, compromise nurses' job satisfaction, and prevent staff engagement.4 Factors associated with workplace stress have been found to profoundly impact an individual's physical and mental health, especially when there is violence, bullying, unsafe conditions, limited resources, or when the needs of the worker or the stressors directly impact the work environment.3-5 Over time, workplace stressors can lead to more serious, chronic health problems such as cardiovascular disease, musculoskeletal disorders, and psychological disorders,3,5 suicidality6,7 and death by suicide.8 These stressors increase the risk for burnout, as well as impair clinicians' ability to maintain safe practices, detect emerging safety threats, level of job dissatisfaction, and retention rates.3-5 The following section provides a brief overview of 2 common workplace stressors that nurses face: violence and bullying.
Acts of workplace violence undermine the health and safety of the workforce. Workplace violence is verbal, written, or physical aggression intended to cause death or serious bodily injury to oneself or others. The aggression may include abusive, intimidating, or harassing behavior, threats, or damage.9 The American Nurses Association's (ANA's) Health Risk Appraisal identified that 1 in 4 nurses have been assaulted at work by a patient or patient's family member.10 The AACN's Healthy Work Environment Survey found that 6,949 (86%) of the respondents reported having experienced at least 1 negative incident of verbal abuse, physical abuse, sexual harassment, or discrimination in the past year.11 Nurses were most likely to experience verbal abuse (83%), physical abuse and discrimination (both at 47%), and sexual harassment (40%).11 In addition, the findings suggested that patients and their families or significant others are the greatest source of harmful or violent incidents, followed by other nurses and physicians. Emergency departments (EDs), inpatient psychiatric settings, and nursing homes are identified as the most frequently reported clinical locations associated with violence.3,12,13
Workplace violence can produce physical and psychological injuries. These incidents can result in lost time from work because of pain, physical limitations, or impairment(s) that results from an assault.13-15 Experiencing a violent event can manifest stress disorders such as anxiety, posttraumatic stress disorder, and acute stress disorder, resulting in nurses requiring mental health treatment to deal with the outcomes from an episode of violence.6 These findings, supported by others,16 highlight the need for nurse leaders to proactively build a culture of safety.
Consider the case of Elise Wilson, RN, an ED nurse who was physically assaulted while delivering patient care, which is used here as an exemplar of the impact workplace violence can have.17 Wilson, a nurse with more than 30 years' experience, was working in the ED of Harrington Hospital in Massachusetts when she almost bled to death after a patient with a history of mental health issues stabbed her 11 times. She was airlifted to a nearby trauma center, underwent 8 hours of surgery, and spent 2 weeks in the intensive care unit. After spending an additional 2 weeks in an inpatient physical rehab facility, she was able to go home. Today, she continues to recover and lobby to advocate for policy change to make it a felony for anyone in a healthcare facility to assault a nurse.
A 2nd common stressor, workplace bullying, is another component of workplace violence. In nursing, bullying threatens nurses' health and ability to work safely. The Joint Commission in 2016 defined workplace bullying as repeated, health-harming mistreatment of 1 or more persons (the targets) by 1 or more individuals.13 This abusive conduct may include 1 or more of the following forms13: verbal abuse, threatening, intimidating or humiliating behaviors (including nonverbal), and work interference or sabotage. In alignment with the ANA's official position statement addressing workplace bullying, safe and reliable patient care can be (and often is) disrupted by intimidating, disrespectful behaviors that prevent collaboration, communication, and teamwork, all of which undermine a culture of safety.10 Addressing workplace bullying highlights the impact of bullying on nurses' health and functioning, on the safety of patients, and on the future of nursing.
In the healthcare setting, 44% of nursing staff members report having been bullied, and in a study of 284 healthcare workers, 38% of healthcare workers reported psychological harassment.13 Often underreported or unreported within a culture of silence in nursing, nurses tend to accept nurse-on-nurse bullying as part of the job, particularly the novice or new graduate nurse. Fear of retribution, fear of continued abuse, pettiness, tolerance of bullying behaviors, and perceived lack of caring by nurse managers are just a few of the reasons that workplace bullying has continued within the professional settings of nursing.18,19
Workplace bullying includes lateral or horizontal violence in nursing.10,13 Lateral violence is defined as behaviors between colleagues involving covert or overt acts of verbal or nonverbal aggression and occurs between individuals on the same level in an organization.10 In the healthcare setting, 44% of nursing staff members report having been bullied, and in a study of 284 healthcare workers, 38% of healthcare workers reported psychological harassment.13 Often underreported or unreported within a culture of silence in nursing, nurses tend to accept nurse-on-nurse bullying as part of the job, particularly the novice or new graduate nurse. Fear of retribution, fear of continued abuse, pettiness, tolerance of bullying behaviors, and perceived lack of caring by nurse managers are just a few of the reasons that workplace bullying has continued within the professional settings of nursing.18,19
Cumulative Workplace Stress Risks Nurses' Mental Health
There is no debate that nursing is an inherently stressful profession. All day every day, nurses deal with fast-paced workflow, workplace violence, bullying, unpredictable changes in patients' conditions, death and disability, and the fear of making errors that can affect a patient's life. The cumulative toll of this occupational exposure can lead to anxiety and depression.6,20-22 There is a known link between burnout and depression.6,21-23 Furthermore, conflict in the workplace and violence against nurses adds complexity to the stress nurses experience, which can lead to suicidality.6 Not surprisingly, burnout and compassion fatigue may cause the distancing of staff from patients and families, resulting in missed care, medical error, and patient harm. Barriers to providing care that a nurse believes the patient deserves can cause moral distress, especially when it feels as though organizational policies are causing that distress. This net effect on patient safety can cause reciprocal stressors for the nurse. Evidence indicates that, within the previous year, approximately 14% to 30% of healthcare providers have been involved in a patient safety event, which resulted in personal, emotional, and professional problems.24,25 In the study of Scott and McCoig,24 1 in 7 staffers reported experiencing a patient safety event within the previous year that caused anxiety, depression, or concerns about being able to perform one's job.
Workplace Stressors and Magnet
To address workplace stressors, violence against nurses, and the delivery of patient- and family-centered care, the Magnet Recognition Program® developed by the American Nurses Credentialing Center recently mandated that Magnet hospitals track all incidents involving physical and verbal violence that take place on campuses and facilities.26 It is not uncommon for workplace stressors that contribute to team conflict lead to adverse patient outcomes such as mistrust, dissatisfaction, and delayed healing for patients and families.27,28 This conflict can, in turn, cause unrest in patients and families, who, already stressed, may become agitated, angry, irritated,29 and potentially violent. This is a contributing factor to why patients and their families, or significant others, are the greatest source of violent incidents toward nurses.11 Environments where colleagues, coworkers, employees, employers, students, and others are treated with dignity and respect can help to decrease workplace stress. Prevention of workplace stressors to reduce the impact and to improve the workplace can increase delivery of care while supporting a culture of safety.10,13,26,30
Prevention-Oriented Framework Offers Solutions
Prevention activities are typically categorized at 3 levels: primary prevention (ie, removing risk factors), secondary (early detection and treatment), and tertiary (reduce complications)30 (Table 1). The literature on workplace stressors mainly focuses on primary prevention, such as training employees on conflict resolution, de-escalation strategies, and nonviolent crisis intervention.14,18,19 Promoting awareness of the link between workplace stress and health among both employers and workers is an important 1st step of workplace health promotion. Healthcare systems that understand, identify, and respond to workplace stressors are best positioned to craft policies and guidelines to promote safe and healthy workplace environments for the nurses in their facilities.18,31 Nurse leaders can use a prevention framework to select targeted strategies to improve healthy work environments.10,14,18,19,30
Creating Healthful and Safe Work Environments: Exemplars
The Quadruple Aim links patient and staff safety inextricably, making an Healthy Work Environment the bedrock of an organizational safety culture. Based on the fact that patients and families suffering from the stress of a medical crisis often instigate violence, healthcare facilities are enlisting the help of their local communities in creating safer workplaces. For example, in the states of Michigan and California, hospital associations and local hospitals have enlisted their communities' help in assuring safety for all by tackling workplace violence with preventive-oriented education. In Michigan, the Hospital Association's Board of Trustees chose workplace safety as a top priority in 2018 and used hospitals' actual OSHA data to drive educational programming for all employees (B. Brogan, MHA Keystone Center, personal communication, September 13, 2019). Analysts from the association reviewed the data to isolate patterns and identify trends. These local efforts focused on collaborative training programs are open to all member hospitals(B. Brogan B, MHA Keystone Center, personal communication, September 13, 2019). Likewise, the Contra Costa Regional Medical Center and Health Centers in California launched an extensive lean initiative with patient, family, and community advisors to redesign its behavioral health emergency care environment and processes.32 The process included building and nurturing patient, family, and community-based partnerships resulting in real-world savings and benefits. As a result of this community-based effort,32 the hospital is:
- Saving 255 staff hours in its ED each month that were previously spent obtaining patient medical clearances.
- Opening up 14% of its ED beds for the general population.
- Saving patients 1000 hours of previously spent waiting time to access the psychiatric emergency services unit.
- Reducing the number of patients discharged on multiple psychotropic drugs.
In addition, several pilot efforts that could prove useful are underway now. These initial efforts include examples of the development of a quick-react protocol that immediately locks down a specific unit or the entire hospital when an incident of work place violence takes place, inserts a flag in the electronic health record (EHR) of any patient who has been involved in a workplace violence incident while being treated in the ED and having clear signage in public places about being a nonviolent and safe zone. Although the effectiveness of these protocols as a bundle is not yet determined, these efforts represent a few of the new strategies that healthcare institutions are implementing to underscore their commitment to assuring the personal safety of their staff.
The 1st step to curb workplace violence and bullying is to have clear policies regarding both verbal and physical abuse.10,13,18,31 National professional nursing organizations can offer resources, expertise, and leadership to assist in reducing workplace violence and bullying. For example, the AACN Standards for Establishing and Sustaining Healthy Work Environments calls for zero tolerance regarding bullying, verbal abuse, and other forms of institutional violence.33 Policies that identify and define workplace violence and bullying as well as provide structure on how to report can break the culture of silence. Evidence suggests that nurses who work in units that are implementing the AACN Healthy Work Environment Standards (such as skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership) report an overall healthier work environment, better nurse staffing, less moral distress and healthier professional relationships.11,33 These units also report fewer incidents of workplace violence than those in units that have not implemented the HWE standards.11
To focus national attention on the need to protect nurses, the ANA, in 2015, adopted a policy of “zero tolerance” for workplace violence and called on nurses and their employers to work together to prevent and reduce violent and abusive incidents.34 In 2017, ANA launched its #EndNurseAbuse initiative to address workplace abuse against nurses, including eliminating sexual harassment.34 The ANA also supports the #TimesUpNow initiative, which mirrors some of the same tenets as the #MeToo movement and communicates to healthcare employers that taking a lackadaisical attitude to nurse abuse is no longer acceptable.34 The Twitter-based national program highlights instances of violence and harassment against nurses, as well as related policy changes being considered.
Having an engaged and productive workforce that provides safe care to individuals, families, and communities is a fundamental goal for healthcare systems.35 Establishing a commitment to a culture of safety within a healthcare system is a crucial component of preventing and reducing errors as well as improving the overall quality of care.36 Organizations with a positive safety culture exhibit a foundation of mutual trust, a commonly held view that patient safety is important, and a belief in effective preventive measures.37 A team-training program designed by AHRQ and the US Department of Defense called TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) is 1 example of an approach nurse leaders can use to build a positive culture of safety and HWE.35,37,38
Programs such as Code Lavender39-41 and Caregiver Support Teams,38 in addition to providing extra support to novice or new graduate nurses, can combat workplace stress. In the Code Lavender programs, all individuals are trained to recognize and acknowledge each other during difficult situations or patient care outcomes. Caregiver support teams, also called 2nd victim prevention programs, identify key people in each department to provide emotional 1st aid to those in need at the moment and the days following difficult events or patient situations. The goal is to prevent the development of 2nd victim syndrome, which happens when an individual feels as though they have become a victim of their work environment. This caregiver support 1st aiders are generally nominated by peers and receive special training to provide private, compassionate emotional support while recognizing when psychological therapy might be needed. For new graduates or novice nurses, the benefit from these programs in addition to resiliency training and skills building to decrease anxiety, depression, and suicidal ideation is recommended.25,29,38-42
Resources for Action
For nursing and healthcare executives who want to take immediate action to safeguard nurses' safety, these 8 specific strategies are offered to add a layer of protection to the patient care environment43:
- Create policies, statements, and supporting procedures to reduce the risk of workplace violence.
- Review hospital policies and highlight every line that is not evidence based and present recommendations to the leadership to enact change. These actions would reduce psychological burden and overregulation by reducing the sheer number of policy statements that nurses need to remember and follow.
- Add prominently displayed signage to the facility can underscore the intent to protect the safety of all who enter patient care environments.
- Examine and strengthen current practices for identifying and flagging patients, family members, and visitors that display a propensity for violence in the EHR.
- Create programs such as Caregiver Support Teams or Code Lavender to spot worrisome behavior and take immediate action and emotional support.
- Build a culture that encourages staff to report incidents of workplace violence.
- Create verbal de-escalation, tactical self-defense, and bystander training programs.
- Integrate communication tools into systematic security rounding to ensure that security personnel and clinicians exchange information about potential threats.
- Install “personal panic buttons,” which trigger a silent alarm and alert a dispatcher of the exact location so that help can be sent.
A number of organizations have provided work tools to help guide these efforts (Table 2).
Nurse leaders have an obligation to address modifiable workplace stressors to create a culture of safety. In the United States, federal law provides that each individual is entitled to a safe workplace that is free from hazards.44 It is our duty as leaders to prevent or minimize workplace stressors, reduce the impact of stressors that have already occurred, and soften the long-lasting impact of ongoing stressors. Health systems need to have processes in place to recognize and address underlying workplace wellness and mental health of employees while delivering high levels of patient care. Creating a HWE requires the engagement of all members of an organization in partnership with the patient/family. Seeking out proactive solutions as well as adapting ones that are working elsewhere to protect the entire care team must be intentional to maintain a healthy work environment. Being successful in this endeavor requires that the 4 aims be viewed as interconnected opportunities to integrate the voices of nurses, staff, employees, and patients and their families into care delivery while keeping workplace stressors at a minimum. Without that critical integration, there is a tendency to create isolated solutions to workplace violence and workplace bullying that mask underlying stressors and move the care emphasis away from where it needs to be—on the safety of patients, family and staff. Nurse leaders can actively begin to address workplace violence, bullying, and cultures of silence with the promotion of work environments that are safe and humane.
Special thanks to Jeffrey M. Adams PhD, RN, NEA-BC, FAAN, Pamela Cipriano, PhD, RN, FAAN, Susannah Rowe, MD, Sharon Pappas, PhD, RN, FAAN, and members of the AAN expert panels Building Health Care System Excellence and Violence.
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