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Feature: CE Connection

Surviving (Even Thriving?) in a Toxic Workplace

White, Paul E.; Schoonover-Shoffner, Kathy

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doi: 10.1097/CNJ.0000000000000289

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Cynthia has worked for 10 years on her unit as a staff nurse. She used to love going to work and appreciated her nurse and physician colleagues who demonstrated respect in their interactions. Cynthia felt she made a difference in patients' lives and was an appreciated member of the team.

Then, after delivering twin boys, the department supervisor decided to step down. Employees assumed things would continue as they had in the past. The first week on the job, the new supervisor held a meeting and told employees things were going to tighten up, saying, “A new sheriff is in town.” Previously, communication had been free-flowing, but after a few months, people were afraid to openly discuss problems. Gossip and hidden agendas began to flourish. One of Cynthia's colleagues began blaming work problems on her. When Cynthia talked to her, the colleague cried, saying her life was in crisis, and Cynthia was too hard on her. Cynthia felt confused and guilty.

The new supervisor began openly embarrassing nurses, technicians, physicians, and other managers. Whereas Cynthia had had a good relationship with the former supervisor, her new one took little interest in employees. Cynicism and fear now rule the workplace. Cynthia feels discouraged, apathetic, and is considering leaving nursing altogether.

THE PROBLEM OF TOXIC WORKPLACES

Sadly, true stories like the above happen all too frequently in healthcare. In their book, Toxic Nursing, Dellasega and Volpe (2013) lament that “Toxic nursing is a real threat to the nursing profession” (p. 289). How big of a threat? Surveys reveal that half plan to leave their jobs within the next three years, due to workplace issues (Dellasega, 2009; Wilson, Diedrich, Phelps, & Choi, 2011). Other studies report that between 27% and 85% of nurses say they are victims of workplace bullying (Becher & Visovsky, 2012; Christie & Jones, 2013; Wilson et al.). A recent survey found that 66% of nurses either experienced or witnessed bullying, naming staff nurses as bullies 58% of the time, physicians 38%, patient care technicians 34%, and nurse managers 34% of the time (Keller, Budin, & Allie, 2016).

Toxic workplaces are more than a threat to employees. Incivility threatens patient safety (Wilson & Phelps, 2013). Wright and Khatri (2015) found that nurses experience a psychological/behavioral response to bullying that impacts medical errors. Toxicity also costs organizations money from absenteeism and turnover (Dellasega & Volpe, 2013).

In addition to being unpleasant, toxic workplaces are professionally unethical. The Code of Ethics for Nurses specifies, “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (American Nurses Association, 2015, p. 1). This includes relationships with colleagues and treating everyone in the work environment with dignity and respect. It also means taking action to prevent harm to others and responsibility to ensure a culture of civility.

In my work (Paul), training managers in healthcare settings to communicate authentic appreciation in the workplace (Chapman & White, 2012), I've heard frequent comments from employees and managers about workplace toxicity. My organization surveyed 40,000 individuals, asking people to share their stories and experiences. Their responses led to follow-up interviews and culminated in the book Rising Above a Toxic Workplace (Chapman, White, & Myra, 2014) and the Ratings of Toxic Symptoms (ROTS) Scale (White, 2015), which assesses the level of perceived negative characteristics in an individual's workplace. This article draws from our workplace surveys and other research about how to survive, if not change and thrive, in toxic workplaces.

Anything that is toxic is essentially poisonous and harmful—hazardous physical waste or a toxic relationship. A toxic workplace has unhealthy characteristics that create damage to employees and potentially to patients, families, and vendors. Common characteristics of a toxic workplace include negativity, gossip, blaming and making excuses, lack of support from administration, bullying, lack of appreciation for work done, inconsistency in applying policies and procedures, poor morale, high staff turnover, and a general sense of discouragement (Dellasega & Volpe, 2013; Keller et al., 2016; Wilson et al., 2011). In our training groups, 90% of participants who have worked in healthcare more than three years indicate they have worked in a setting characterized by these symptoms. Three primary areas are common in unhealthy work environments: sick systems, toxic leaders, and dysfunctional colleagues.

1: SICK SYSTEMS

When individuals discuss toxic workplaces, initial thoughts seem to focus on negative comments about leaders and other employees. However, we found that poor or misunderstood procedures or policies often underlie a toxic work environment, resulting in an overall sick system. When the foundational structure of an organization is not built well (or not functioning well), unhealthy behaviors typically follow. What are the elements of this foundational structure?

Poor Communication Patterns are the hallmark characteristic of structural problems within the sick organization. This can occur between colleagues; between supervisor and supervisees; and up, down, and throughout the organizational structure. Obviously, the more frequently communication problems occur (and in multiple types of relationships), confusion increases, and it becomes less likely that good decisions will be made and implemented.

The most problematic form of poor communication is a lack of communication. When individuals do not communicate with one another, the necessary information to make correct decisions and actions is absent Furthermore, individuals tend to infer what information is lacking, which leads to errors in understanding the true facts. There are different ways to not communicate, including not saying (or doing) anything, not responding to others' messages (e.g., not replying to e-mails), avoiding interaction or saying, “I'll get back to you,” but not doing so.

Another way to miscommunicate involves communicating inaccuratemessages. This can be characterized by giving partial information, distorted information, incorrect data, or making incorrect inferences from data. A staff member may honestly report they are late to work “because there was an accident on the freeway.” But they may neglect to say they left home 20 minutes late, as well. Someone may report being unable to finish assigned patient care due to “a busy shift,” but neglect to say they took multiple breaks. Christians are called to “speaking the truth in love” (Ephesians 4:15, NIV), meaning we tell the truth (versus not say anything, or a white lie) but do so in a way that honors Christ (versus passive-aggressive, etc.).

The third problem is utilizing indirect communication. Indirect communication can occur by trying to go around the individual to whom the message or request should go. Another form is to send information through a messenger. The purpose is to avoid the negative interaction that occurs when the information is communicated, or, not wanting to be held responsible for a lack of getting a task done.

Mixed messages are when the content of the message does not match the nonverbal presentation. An example is saying, “I'm not angry!” when someone clearly is upset. Or, the current message is inconsistent with prior information communicated, as when the message says to do something that previously was against the rules.

The final form of miscommunication includes not checking for understanding. Most agree (intellectually, at least) that the responsibility for clear communication lies with both the sender and receiver of the message. The only way to make sure the message received is the message that was intended is to use a process of checking back to assess that the receiver has clearly understood the message intended.

Policies Not Followed: Healthcare settings have detailed standard operating policies and procedures for patient care, related to federal and state government laws, rules, and regulations; professional regulations; procedures demanded by insurance companies; and institutional policies and regulations. Other unit-specific procedures related to work assignments, scheduling time off, and general unit management are required by one's supervisor. Although healthcare workers will always follow policies to ensure patient safety, some can begin to pick and choose which nonpatient care-related policies they will follow and which they will not follow as specifically. There are a number of reasons why policies may not be followed, such as a lack of procedures being in place (unlikely in healthcare settings), poorly designed processes, or processes not being followed.

When policies are not followed, there generally are four reasons. First, employees may not have been trained adequately. In actuality, some initial training almost always is given for new employees or new policies. However, especially when an employee is new, he or she is overwhelmed with the amount of information to process. This, combined with normal anxiety, results in poor processing and recall. It is important for training processes to have ongoing instruction and review as part of training and follow-up. In fact, Warner, Sommers, Zappa, and Thornlow (2016) found that training through a quality improvement program increased awareness of and decreased instances of workplace incivility.

The second reason policy may not be followed is lack of oversight and accountability from supervisors. Managers can be overwhelmed and not sufficiently monitor whether policies are followed. Over time, this can lead to a lack of compliance. Furthermore, managers need adequate training to be effective and may not receive it.

Some managers avoid conflict, which is the third reason policies may not be followed. Although supervisors may be aware of noncompliance, given their personality style (and that of their team members), they choose not to deal with a problem, due to confrontation avoidance.

A sense of resentment also can lead to policies not being followed. We found that when employees do not feel valued and appreciated, they start to rebel passively and feel they do not need to comply. Because employees do not feel valued by their supervisor or employers, why should they strictly adhere to policies? Over time, passive rebellion can lead to more active acting out (complaining, gossip, bullying, etc.).

Lack of Clearly Defined Rules and Responsibilities is a third major component of sick systems. This can occur when there has not been a clear definition of one's position and the tasks for which they are responsible. This is especially common in a new position or when individuals share responsibilities. When employees are not clear about what they are supposed to do, most tend to not do the task (it is less common to take on more responsibility than assigned). This confusion becomes a breeding ground for employees to make excuses and blame others when tasks don't get done. If it is not clear who is responsible, it is easy to pass off responsibility. Practically, when roles and responsibilities are not clearly defined, customer service declines, as tasks fall between the cracks. Additionally, when patients ask questions, they may be given different answers. This becomes highly frustrating for the patient or their family.

IMPROVING SICK SYSTEMS

One of the challenges in dealing with organizational/structural issues is the limited power and influence most employees have to impact change in the organization at large. Employees become frustrated because the problem is with the system, and they feel powerless to effect change.

However, individuals do have the ability to change their behavior and influence colleagues on a daily basis. We found three positive actions that can make a difference in an individual's daily sphere.

First is commit to direct communication. The single most impactful action an individual can make is to communicate directly (versus indirectly) with those around him or her. This includes: (a) go through the correct channels for information and decisions, and (b) focus on talking to those directly involved with an issue, rather than talking to others who are not directly involved. For Christians, the Bible strongly supports this approach to communication (i.e., Proverbs 17:9; Ephesians 4).

Second, clarifying individual responsibilities leads to clarity within the work group. This is especially true in group meetings where decisions have been made about future actions. Often, at the end of the meeting, it is unclear who is to do what. Working at clarifying (a) what specific actions are to be done, (b) who is responsible for each action to be done, and (c) a target date by which actions will be reviewed, and (d) to whom the responsible party is to report progression, makes a significant difference in clarifying actions from meetings.

Third, when individuals proactively collaborate with colleagues on tasks, this helps facilitate communication. Proactive collaboration can help develop a sense of teamwork and also communicate that others' knowledge and skills are valued and needed.

2: TOXIC LEADERS

The second common characteristic of an unhealthy workplace is the presence of toxic leaders at some level. A toxic leader can be at any level of the organization from Chief Executive Officer to a shift supervisor, such as the charge nurse. Obviously, the more toxic leaders scattered across the organization, the less healthy the organization. Interestingly, most toxic leaders actually have some positive traits and characteristics. They often look good initially, otherwise, they would not have been hired. However, it becomes clear over time that they were able to cover their negative characteristics, or they put a positive spin on issues that eventually create problems. In our work with toxic workplaces, we found 10 common characteristics of toxic leaders (Table 1).

Table 1:
Table 1::
Top Ten Characteristics of Toxic Leaders

A key aspect for understanding toxic leaders is that they are extreme about achieving goals. They are all about getting the job done, regardless of what it takes and the costs to others. Sometimes these goals are the goals of the organization, but often the goals can be personal goals (for self-advancement or ingratiation). They use organizational goals to help further their personal goals.

Toxic leaders, by nature, are manipulative. That is, they manipulate people and information to their own ends. Manipulation is the process of using someone or something for your own goals. Toxic leaders can be quite effective in manipulating information. They control and withhold information, only sharing with certain individuals (or in certain ways), or distorting information to look positive when it is not.

Toxic leaders are narcissistic. They view the world almost solely from their point of view, and often they see themselves and act as though they are the center of the universe. They believe they are the best, most talented, and smartest individual and that they are almost always right. Therefore, they believe they should be treated specially. Typically, they do not believe rules, policies, and procedures apply to them. Clearly, these characteristics are opposite of how Christians are exhorted to think and act (Philippians 2:3-4).

Toxic leaders are talented at taking the credit for others' successes. If a positive result has occurred, they take credit and explain how their actions and decisions led to that positive outcome. They have no compunction about receiving the positive rewards associated with others' work (and they have no problem blaming others for any and all errors or mistakes).

Relating to others in a condescending way is another characteristic of toxic leaders. Because they view themselves as better than others, they routinely make negative critical comments, correcting others in public, putting others down, and relating in a way that communicates they are in a superior position.

Toxic leaders become known for their inauthenticity. This can include an overstatement of their education, training, experience, and skills. What they have portrayed versus their real selves are two separate entities. Some toxic leaders have smooth social skills and relate in a charismatic way, whereas those close to them see their disdain for others and a genuine lack of caring.

In addition to manipulating information, toxic leaders use others. People are essentially a tool or resource to help them achieve their goals. Others are expendable; it is fine to use you up and throw you away. These leaders care more about themselves.

Toxic leaders, over time, often do not address real risks. When circumstances (e.g., funding needs) do not line up with the goals they are pursuing, they can ignore the issues, minimize, or delegate to others, in part so they can blame someone when the situation does not go well. As a result, toxic leaders can lead organizations into significant problems.

Lastly, toxic leaders have a knack for leaving before things fall apart. They seem to identify when reality is going to hit, and they move on to another position. As a result, they are able to jump from one organization to another, leaving a trail of damaged institutions behind and avoiding personal loss associated with their practices.

DEALING WITH TOXIC LEADERS

What are positive actions you can take when working for a toxic leader? First, remember that he or she is inwardly focused. As a result, s/he will use people to avoid accountability for decisions or actions. It is important to take a defensive posture of protecting yourself. This includes

  • Do your work correctly and if unsure about something, ask;
  • Document everything you do in some way;
  • Document all interactions related to decisions made, instructions given, etc. (e.g., with a follow-up email to you and your boss);
  • Ask leaders to document instructions and requests in writing;
  • Include other individuals in key meetings with leaders so a third party is present.

When working for toxic leaders, employees can become confused about what is right and normal. It is critical to seek support from an objective party who can give you input and perspective. Often, working for a toxic leader leads individuals into gray areas of ethics, morality, and legalities. Having a wise person of counsel next to you is strongly suggested (cf. Proverbs 13:20).

3: DYSFUNCTIONAL COLLEAGUES

A third key component of an unhealthy toxic work environment is when you work with one or more significantly dysfunctional people. We use the term dysfunctional in a descriptive sense, not in a pejorative or labeling sense. Rather, people who are dysfunctional have a problem with functioning in one or more areas of their lives. Dysfunctionality can be demonstrated in long-term relationships, inability to maintain employment, chronic financial difficulties, drug and alcohol abuse, verbal, emotional and physical abuse of others, and other addictions such as gambling.

When examining those characteristics that lead individuals to a long-term healthy lifestyle (as opposed to a dysfunctional lifestyle), core characteristics have been identified (Table 2). Overall, individuals who communicate honestly and have integrity between what they say and what they do, as opposed to not telling the truth or withholding information, tend to do better. Also, communicating directly with those involved leads to healthy communication patterns. Individuals who understand they must demonstrate responsibility before experiencing privileges tend to progress in their careers more than individuals who have a sense of entitlement and being given privileges before demonstrating accompanying responsibility.

Table 2:
Table 2::
Key Differences Between Functional and Dysfunctional People

Accepting responsibility for one's choices is a key component. Everyone makes mistakes, but individuals who accept the responsibility (and consequences) for mistakes or poor choices tend to function better at work than those individuals who consistently deny responsibility for actions, blame others, or repeatedly make excuses for their choices. Healthy individuals tend to learn from their mistakes, whereas dysfunctional individuals seem to expect to be rescued from the consequences of their choices. Sadly, this pattern can repeat indefinitely (note the fool discussed in Proverb 26:4-5).

People who delay gratification, working for rewards over the long term, tend to make better decisions than those demanding instant gratification. And, although there are numerous differences between functional and dysfunctional individuals, a key characteristic is that healthy individuals tend to be real and genuine—they are who they are. Dysfunctional individuals focus on presenting a certain image and appearance to others, which often is not reality-based.

Although there are obvious patterns associated with functional versus dysfunctional people, overall, unhealthy individuals relate in ways that cause distress. These relational patterns include

  • Framing an issue as a crisis that has to be dealt with immediately (although the crisis has been developing over time);
  • Being adept at making those around them feel like problems are not their issue but yours;
  • Creating false guilt; if you don't help them, you are insensitive and uncaring (“How can you call yourself a Christian?”);
  • Feeling fogged and confused about a situation after talking with dysfunctional individuals; you may question your prior beliefs and thinking about the situation;
  • Creating problematic situations, and if you don't intervene, the consequences may be severe. The problem may ruin the dysfunctional person's life (personally or professionally); may make you, your department, or the organization look bad; or there may be negative consequences to others (patients and families).

DECREASING DYSFUNCTION

The challenge in talking about dysfunctional individuals is that we almost always frame the dysfunctional person as being someone else. Rarely do we think about ourselves as being dysfunctional. The focus becomes on others being the problem and the one(s) who need to change.

In reality, all of us are bent to some degree. Scripture teaches that our hearts are deceitful (Jeremiah 17:9), and we all make mistakes (Psalm 106:6; Romans 3:23). We have an innate propensity toward not doing the right thing, including not telling the truth, being overly focused on ourselves, and blaming others. It is therefore important when discussing toxic workplaces and dysfunctional qualities to stop, reflect, and ask: “In what areas do I lean toward the dysfunctional side, and what steps can I take to prevent acting in these ways?”

First, it is important to do a self-assessment to determine how we contribute to unhealthy interactions. We all have the capability to make situations worse by contributing to negative interactions, failing to correct misleading information, or by being passive and doing nothing.

Second, it is important to accept that you cannot change the other person. We intellectually assent to this, but our speech belies our thoughts because we often state, “Why don't they just....?” or “If they would only....” The reality is we are never able to change someone else. We can set an example of healthy behavior. And remember, the best predictor of future behavior is present behavior.

Third, when dealing with dysfunctional individuals, understand that you will likely feel blamed or responsible for whatever the problem is. Avoid taking responsibility for things you did not do. Plan ahead for how you will handle accusations and what you will state about your contribution to a problem.

With regard to the issue of rescuing an individual from their choices, it is important (ahead of time, if possible) to set boundaries regarding what you are and are not willing to do. We may be willing to help a colleague to a certain degree, but not fully complete all of his or her responsibilities. We may be willing to work extra to cover someone's shift and/or extra break, but only once every two months. We may be willing to loan them $20 one time, but no more. You are wise to seek support and input from an outside, objective individual, who can help you assess the situation with a dysfunctional colleague.

KEY TO STOPPING TOXICITY: OUR RESPONSE

One difficulty in explaining factors that lead to unhealthy workplaces is the tendency to focus on external factors—the sick systems, toxic leader, or dysfunctional colleagues. However, a key component to the health of any workplace (and our individual experience of it) is our response. Who we are, our attitudes, behavior, and speech are key components that impact us and those around us.

Toxic workplaces are sometimes noted in the literature from a victim mentality: Woe is me! See how bad my job is! But this is an unhealthy perspective. Focusing on Wo! I work in such a bad place! does not help anyone. It's important to look at our options in dealing with the situation. Bible teacher John Maxwell states, “Life is 10% what happens to me and 90% how I react to it” (Goodreads, 2016).

Working in a toxic environment can be overwhelming. It can feel like so much is wrong that it's discouraging to know how to make a difference. But one person can influence not only their interactions, but the interactions around them. Although you may not be able to correct major structural problems, you can start in small ways.

An important principle is just start somewhere. Inaction in a toxic workplace is your greatest enemy. Things you can do include

  • Commit to focusing on direct communication;
  • Make authentic, positive comments to others;
  • Don't engage in negative interactions, excuse yourself and walk away (Ephesians 4:29-32);
  • Turn negative gossip into positive conversation, say good things about others (Grosser, Lopez-Kidwell, & Labinca, 2010);
  • Work at clarifying your roles and responsibilities, including responsibilities for tasks agreed on in meetings;
  • Set limits on what you are willing and not willing to do;
  • Do what you say you will do. “Let your ‘Yes’ be ‘Yes,’ and your ‘No,’ ‘No’” (Matthew 5:36-37, NIV);
  • Document interactions, conclusions, and decisions made;
  • Seek outside counsel from a healthy individual, perhaps an older person (Job 12:12);
  • Don't seek counsel from unhealthy individuals (Psalm 1:1);
  • Don't engage in rescuing dysfunctional colleagues;
  • Examine Christian responses offered in the sidebar “Where's the Thriving?” and “The Right Thing to Say” (p. 133).

Positive actions can begin to make a difference in negative work environments, regardless of one's role or position in the organization. At some point, you may decide that the best action is to seek employment elsewhere. That action also can help others realize change is needed.

Let's go back to Cynthia and her toxic workplace. What is sick about the system? How is her new supervisor a toxic leader? In what ways is her colleague dysfunctional? Most importantly, based on what you've learned here, what are steps Cynthia can take to survive in this toxic environment? By identifying key steps for Cynthia, you are on your way to change, surviving in your difficult workplace.

Where's the Thriving?

Is it realistic to think we can thrive in toxic workplaces? For the Christian nurse, God promises to help us survive in difficult situations (cf. Psalm 23). He also intends for life's difficulties to help us grow. James, an earthly brother of Jesus, was leader of the Jerusalem church in the decade after Christ's resurrection. The church was growing, in spite of increasing widespread opposition. He wrote to the church:

Consider it pure joy, my brothers and sisters, whenever you face trials of many kinds, because you know that the testing of your faith produces perseverance. Let perseverance finish its work so that you may be mature and complete, not lacking anything. James 1:2-4, NIV

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James suggests that tests and challenges can grow us spiritually as we cry out to God and work to understand what he wants to do in our lives and the lives of those around us. James goes on to say (1:5-6, NIV), “If any of you lacks wisdom, he should ask God, who gives generously to all without finding fault, and it will be given to him. But when he asks, he must believe and not doubt....”

How does God give wisdom? He speaks to us through the Bible and spending time with him in prayer, worship, and with other believers. Jesus promised a Counselor, the Holy Spirit, who would guide us into all truth (John 16:13). As you study Scripture, pray, and talk with wise counselors, ask God to give you specific guidance for your work situation.

For example, Ephesians 6 teaches us to put on spiritual armor. Like a fully-armed soldier prepares for battle, put on truth, righteousness, the gospel, faith, salvation, and the Word of God. Applying this passage will help prepare you for spiritual battles at work. We also are told in Ephesians 6 to pray on all occasions with all kinds of requests (v. 18). Serious prayer or intercession for colleagues and the workplace is essential and powerful (1 Peter 3:12). Pray daily, during work, and especially in difficult situations. Ask other Christians to pray with you. Ask God for patience and wisdom (Job 12:13). When needed, overlook transgressions and forgive (Proverbs 19:11; Ephesians 4:25-32).

Other great Bible passages for dealing with toxic workplaces focus on our speech. Psalm 15 says be blameless, do what is righteous, speak the truth from your heart, have no slander on your tongue, do your neighbor no wrong, cast no slur on others, and concludes, “He who does these things will never be shaken” (v. 5, NIV). Read through the Proverbs, which contain numerous references to our relationships with others and our speech.

The thriving in difficult situations comes as we learn and grow. Thriving comes as we act like Jesus and shine sparks of light in our workplace. God may lead you to leave a toxic workplace, but you will leave well, as you follow his plan. God's instructions to “Live a life worthy of the calling you have received. Be completely humble and gentle; be patient, bearing with one another in love” (Ephesians 4:1-2, NIV), offer a higher calling to pursue, as we deal with the challenges of a toxic workplace.

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References

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Becher J., Visovsky C. (2012). Horizontal violence in nursing. Medsurg Nursing, 21(4), 210–232.
Chapman G. D., White P. E. (2012). The 5 languages of appreciation in the workplace: Empowering organizations by encouraging people. Chicago, IL: Northfield.
Chapman G. D., White P. E., Myra H. (2014). Rising above a toxic workplace: Taking care of yourself in an unhealthy environment. Chicago, IL: Northfield.
Christie W., Jones S. (December 9, 2013). Lateral violence in nursing and the theory of the nurse as wounded healer. Online Journal of Issues in Nursing, 19(1). doi:10.3912/OJIN.Vol19No01PPT01
Dellasega C. A. (2009). Bullying among nurses. The American Journal of Nursing, 109(1), 52–58.
Dellasega C., Volpe R. (2013). Toxic nursing: Managing bullying, bad attitudes and total turmoil. Indianapolis, IN: Sigma Theta Tau International.
Goodreads. (2016). John C. Maxwell quotes. Retrieved from http://www.goodreads.com/author/quotes/68.John_C_Maxwell
Grosser T., Lopez-Kidwell V., Labinca G. (2010). A social network analysis of positive and negative gossip in organizational life. Group & Organization Management, 35(2), 177–212. doi:10.1177/1059601109360391
Keller R., Budin W. D., Allie T. (2016). A task force to address bullying: How nurses at one hospital implemented an antibullying program. American Journal of Nursing, 116(2), 52–58. doi:10.1097/01.NAJ.0000480497.63846.d0
Warrner J., Sommers K., Zappa M., Thornlow D. K. (2016). Decreasing workplace incivility. Nursing Management, 47(1), 22–30.
    White P. E. (2015). Ratings of Toxic Symptoms Scale. Retrieved from http://shop.appreciationatwork.com/products/ratings-of-toxic-symptoms-scale
    Wilson B. L., Diedrich A., Phelps C. L., Choi M. (2011). Bullies at work: The impact of horizontal hostility in the hospital setting and intent to leave. The Journal of Nursing Administration, 41(11), 453–458.
    Wilson B. L., Phelps C. (2013). Horizontal hostility: A threat to patient safety. JONA'S Healthcare Law, Ethics and Regulation, 15(1), 51–57. doi:10.1097/NHL.0b013e3182861503
    Wright W., Khatri N. (2015). Bullying among nursing staff: Relationship with psychological/behavioral responses of nurses and medical errors. Health Care Management Review, 40(2), 139–147.

    Names changed to protect privacy.

    Keywords:

    bullying; dysfunctional behavior; healthcare; nursing; organizational communication; toxic workplace

    InterVarsity Christian Fellowship