Secondary Logo

Journal Logo

Department: Pathway to Excellence®

Addressing workplace violence with the Pathway to Excellence® framework

McCright, Maggie MSN, RN, NE-BC; Blair, Mendy DNP, RN-BC, CENP, NE-BC; Applegate, Beverly MSN, RN, WCC; Griggs, Phyllis MSN, RN, CPHRM; Backus, Marcie BSN, RN; Pabico, Christine PhD, RN, NE-BC

Author Information
Nursing Management (Springhouse): August 2019 - Volume 50 - Issue 8 - p 10-13
doi: 10.1097/01.NUMA.0000558480.62072.24
  • Free

Workplace violence, incivility, and bullying play a significant role in nurse job satisfaction and intent to leave.1 This emerging trend is alarming and requires attention for several reasons. According to the 2019 National Healthcare Retention & RN Staffing Report, the total hospital turnover rate stands at 19.1%. Nursing turnover is costly, ranging from $40,300 to $64,400 to replace one clinical nurse, which could result in an average cost to hospitals of $4.4 to $6.9 million.2 As factors affecting workforce retention, bullying, harassment, and horizontal violence are contributors to high turnover costs.3

In addition to affecting turnover, workplace violence, incivility, and bullying can result in poor health effects (physical and psychological), decreased self-worth and confidence, impaired nursing judgment, and decreased productivity.1 For organizations to maintain the current nursing workforce and prepare for the future, it's vital to address these issues and provide a healthy and respectful practice environment. Both the American Nurses Association (ANA) and The Joint Commission have come forward with key recommendations to address workplace violence, incivility, and bullying that include providing healthy, supportive practice environments.1,4

The American Nurses Credentialing Center's Pathway to Excellence® Program provides a framework for a positive practice environment that fosters a culture of nurse engagement and empowerment, interprofessional collaboration, and staff well-being. Three of the six Pathway standards can serve to mitigate workplace violence, incivility, and bullying: The safety standard ensures that the organization protects nurses, staff, and patients through safety policies and practices; the quality standard provides for organization-wide education sessions on respectful communication; and the well-being standard protects against burnout by promoting wellness and work-life effectiveness.


The Occupational Safety and Health Administration (OSHA) defines workplace violence as “any act or threat of physical violence, harassment, intimidation, or threatening disruptive behavior that occurs at the work site.”5 Workplace violence arises in various forms that impact respect, safety, and interprofessional communication. According to a summary provided by The Advisory Board Company, 25% of nurses reported workplace violence in 2016, and the rate of healthcare workplace violence from 2005 to 2014 increased by 100%, with 75% of all workplace violence taking place in healthcare—a statement paralleling OSHA's report that workplace violence in healthcare settings from 2002 to 2013 was four times more common than in other industries.6,7 Fifty percent of 10,688 nurses reported being bullied in a health risk appraisal survey completed in 2016 by the ANA.8 These statistics may even be underestimated given that organizations are thought to be underreporting due to lack of a reporting policy or lack of a perceived safe environment that eliminates fear of retaliation.7

The ANA defines incivility as rude and discourteous actions, gossiping and spreading rumors, or refusing to help a coworker. Bullying is repeated, unwanted harmful actions intended to humiliate, offend, and cause distress to the recipient.1 The frequency of incivility and bullying is difficult to determine because it's often underreported and not often identified as a reason for turnover. However, these acts of workplace incivility can be devastating to nurses, impacting job performance, well-being, and the commitment to continue working in the organization.9

What can be done? Among the key ANA and Joint Commission recommendations offered to employers are several for creating essential infrastructures to mitigate the occurrence and effects of workplace violence, incivility, and bullying:1,4

  • develop, maintain, and enforce a zero-tolerance policy for workplace violence, incivility, and bullying
  • establish a culture of respect and safety that's foundational to the organization's mission, values, and philosophy
  • ensure staff awareness of workplace violence, incivility, and bullying policies during orientation and then through frequent updates
  • provide education and practice conflict negotiation/resolution skills
  • encourage and support self-care, stress reduction and management, fatigue reduction, and resilience training
  • offer ongoing support for those who've experienced workplace violence
  • have systems in place that encourage and allow staff to report violence, including verbal abuse, and track and trend all reports.

Pathway to Excellence framework

Pathway's mission is to guide the positive transformation of practice environments to build a global community of healthcare organizations committed to nursing workplace excellence. The Pathway to Excellence Program addresses workplace violence, incivility, and bullying by establishing the foundations of a healthy workplace for all nurses. The program supports a culture of respect and safety through standards focused on shared decision-making, leadership, safety, quality, well-being, and professional development. These standards serve as a framework for organizations and nurses to transform the workplace culture and practice environment. In particular, the safety, quality, and well-being standards support the development of a practice environment free of workplace violence, incivility, and bullying.

The Pathway to Excellence safety standard requires organizations to demonstrate how they monitor concerns regarding professional practice behaviors and include nurses in addressing any unfavorable trends. This standard also requires organizations to describe how they protect patients, family, and staff from workplace violence. In addition, the safety standard empowers clinical nurses to have input into safety policies and procedures.

Because a culture of respect is vital for nurses to establish healthy relationships with others, education and training on respectful communication and collaboration among employees are foundational in a positive practice environment.1 The Pathway quality standard requires organizations to document the educational sessions they provide to facilitate respectful communication and collaboration among employees.

The well-being standard, unique to the Pathway program, was included in the framework to promote a focus on nurses' personal well-being in addition to other practice environment factors that can help address the high rates of burnout in hospital settings.10 This emphasis on safeguarding nurses' well-being aligns with the ANA's definition of a healthy nurse as “one who's actively focused on creating and maintaining a balance and synergy of physical, intellectual, emotional, social, spiritual, personal, and professional well-being.”1 The well-being standard includes nurse participation in the assessment of employee wellness and the identification of organizational initiatives to promote work-life efficiency.

Using the Pathway framework to impact workplace violence

One example of how a Pathway-designated organization has addressed workplace violence, incivility, and bullying is illustrated by Baptist Health Richmond (BHR). Initially designated a Pathway to Excellence organization in 2016, BHR is a rural community hospital in a multihospital system located in Richmond, Ky. At BHR, leaders recognized an increase in concerns from nurses and staff regarding workplace safety. Many nurses and staff members reported that dealing with workplace incivility was “just part of the job.” Although few formal reports were submitted related to workplace safety, BHR leadership made improving and enhancing processes, policies, and structures to support the safety of their nurses an immediate, focused priority.

Strategies put into place included:

  • annual online learning modules for staff related to disruptive behaviors, domestic threats, self-awareness, predisposing and precipitating factors, active shooter training, and Code 5 response teams
  • a nonretaliatory incident reporting system, observing a just culture philosophy whereby staff members are encouraged to report concerns related to physical and verbal abuse and bullying
  • signs indicating zero tolerance for all forms of aggression placed throughout the facility at public entrances and elevators
  • space allotted in the ED for a police substation
  • a collaborative partnership with local law enforcement
  • full-time security staff assigned to the ED
  • de-escalation training for security/staff
  • limited access into the hospital after 10 p.m. to mitigate the potential of staff isolation in work areas
  • a Code 5 response team to provide support to staff members who may feel threatened.

The well-being standard is most prominently supported at BHR through:

  • encouragement of a healthy lifestyle for staff through healthy menu options, personal wellness classes, picnic tables, a relaxation room, and a healing garden
  • a free, confidential Employee Assistance Program for help with resiliency, emotional wellness, workplace success, work-life balance, and personal and family goals
  • nursing seminars related to compassion fatigue and ways to combat burnout
  • a wellness committee focused on self-care of the caregiver
  • flexible scheduling to assist in achieving work-life balance.

Specific metrics demonstrate BHR's successful translation of the Pathway standards into its culture. Since designation in 2016, BHR has reported a 300% increase in OSHA recordable events related to workplace violence. This increase has been attributed to the numbers of nurses and staff members who cite feeling more comfortable in reporting disruptive behaviors. Through a positive practice environment, BHR leadership continues to work to transform the culture by encouraging nurses and staff to feel comfortable reporting workplace violence, incivility, and bullying.

Support and opportunities

When workplace violence, incivility, and bullying exist, the results are an unsafe work environment. An organization's commitment to safety and well-being for its nurses must include prevention strategies and processes supporting zero tolerance for such incidents, resulting in a culture striving to be free from workplace violence, incivility, and bullying. With the Pathway to Excellence Program, organizations can provide a positive practice environment that fosters a culture of nurse engagement and empowerment, interprofessional collaboration, and staff well-being.


1. American Nurses Association. Incivility, bullying, and workplace violence. 2015.
2. Nursing Solutions Inc. 2019 national healthcare retention & RN staffing report. National Health Care Retention Report.pdf.
3. Vessey JA, Demarco R, DiFazio R. Bullying, harassment, and horizontal violence in the nursing workforce: the state of the science. Annu Rev Nurs Res. 2010;28:133–157.
4. The Joint Commission. Physical and verbal violence against health care workers. 2018.
5. US Department of Labor, Occupational Safety and Health Administration. Workplace violence.
6. The Advisory Board Company. The alarming stats on violence against nurses. 2016.
7. US Department of Labor, Occupational Safety and Health Administration. Workplace violence in healthcare: understanding the challenge. 2015.
8. American Nurses Association. Executive summary: American Nurses Association health risk appraisal. 2017.
9. Warrner J, Sommers K, Zappa M, Thornlow DK. Decreasing workplace incivility. Nurs Manage. 2016;47(1):22–30.
10. McHugh MD, Kutney-Lee A, Cimiotti JP, Sloane DM, Aiken LH. Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Aff (Millwood). 2011;30(2):202–210.
Wolters Kluwer Health, Inc. All rights reserved.