Bullies And Incivility In Nursing Essay Paper

Bullies And Incivility In Nursing Essay Paper

Bullies And Incivility In Nursing Essay Paper

Undergraduate nursing programs include a combination of classroom work, simulation activities and professional experience (clinical) placements. Clinical placements are integral components of programs where students can immerse themselves in “real world” nursing practice. They experience firsthand the clinical work and culture of nursing in health care services. Nursing students completing their clinical placements are vulnerable to workplace stressors as a result of their position in the healthcare hierarchy, particularly given that they are not permanent employees of the organisations in which they are placed.Bullies And Incivility In Nursing Essay Paper

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The American Nurses Association Code of Ethics implores nurses to maintain caring and professional relationships with colleagues as well as with patients and their families. Provision 1.5 of this code specifically states that the nurse must “create a culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect” (American Nurses Association, 2015, p. 4). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the primary authority in healthcare regulation. The Joint Commission has issued a mandate for institutions to address uncivil behaviors in healthcare as they create a threat to patient safety.

Despite these directives, nurse-to-nurse hostility is a known problem according to the past 25 years of professional literature (Embree & White, 2010). Inter-collegial hostility, or incivility, is particularly prevalent in the nursing profession versus non-nursing vocations. This is an enigma, as the nursing profession is based upon interpersonal relationships and the care of others.Bullies And Incivility In Nursing Essay Paper

Civility is defined as the display of polite and courteous acts and expressions that show regard for others (Clark & Carnosso, 2008). Clark & Carnosso, in a concept analysis of civility, find that civil behavior includes tolerance, listening, accepting other viewpoints without negativity, respecting differences, treating one another with dignity and honor, and engaging in social discourse (2008). Civility not only denotes particular behaviors but also describes an attitude of respect for other persons. The word civility has Latin roots in the word ‘civilitas’ meaning community or city. Civility is more than just polite behavior; it is a prerequisite for humans to live together and function as a community. Thus, civility has been described as active engagement in creating and participating in a group or community (Clark & Carnosso, 2008).

Conversely, incivility can then be understood to delineate impolite, discourteous, rude conduct that shows a disregard or disrespect for others. Common forms of incivility in nursing are non-verbal innuendos, verbal affronts, condescending language, impatience, reluctance or refusal to answer questions, disrespect, and undermining (Embree & White, 2010; Weinand, 2011). Unlike civility, uncivil behavior purposely keeps others out of the in-group, e.g. the community.Bullies And Incivility In Nursing Essay Paper

Nursing has been considered the primary occupation at risk for horizontal violence and workplace bullying. Studies estimate that approximately 85 percent of nurses are victims of incivility and up to 93 percent of nurses’ report witnessing incivility in the workplace (Christie & Jones, 2014; Lachman, 2014). Studies comparing nursing versus non-nursing work environments find a rate of incivility at 85 percent in nursing work environments, compared to 75 percent in non-nursing occupations (Hunt & Marini, 2012). Additionally, non-nursing occupations generally report managers as the perpetrators of bullying in a top-down relationship of power (Hoel et al., 2010). Unique to nursing is the prevalence of incivility between workers with equivocal levels of power. Patient care environments may be particularly susceptible to incivility due to high-emotions, stressful conditions, challenging and difficult work, and diverse roles and interactions. Nonetheless, nurses as a distinct sector of the healthcare team have a particular propensity toward uncivil treatment of each other.

Workplace incivility (WPI) is a significant problem in healthcare centres, disturbing not only the clinicians enduring the negative behaviors but also the care that is delivered under the shadow of incivility.[1] Hutton and Gates stated that “incivility is characteristically rude and disrespectful, revealing a lack of respect for others.[2]Bullies And Incivility In Nursing Essay Paper

Individuals who experience incivility, either as targets or witnesses, may suffer numerous negative behavioral, psychological, and somatic effects.[3,4,5,6,7,8,9,10,11,12,13,14,15] In addition, threatening and disruptive actions can also lead to medical errors, reduce patient satisfaction, and increase the cost of care; meanwhile, with the recent modifications in the health care system, such concerns have become even more crucial to address.[16]

The incidence rate of incivility, in terms of experiencing incivility or witnessing WPI was reported to be 11 to 99%.[17,18,19,20] High prevalence of incivility and even violence is reported in Iran,[21,22,23] and some studies even see it as inevitable.[24] Therefore, in this case, further investigation and clarification of the perspectives regarding prevention methods is warranted. However, a limited number of surveys, to our knowledge, have focused on the attitudes which nurses, as the major staff in the health care system, have regarding incivility prevention. Many studies have been published about WPI but most have focused on the frequency, types, and significance of uncivil behavior in healthcare organizations. Meanwhile, describing the experience of incivility prevention from nurses’ perspective is valuable to a better understanding of its risk factors, outcomes, and ways of prevention. Exploring these perspectives is important because they could affect the way nurses are challenged to prevent and manage incivility.[25,26]Bullies And Incivility In Nursing Essay Paper

This qualitative study is aimed at determining how to prevent WPI from nurses’ perspective. The findings of the study may provide a valuable understanding into the perspective of nurses toward the prevention and management of WPI.

While bullying in the healthcare workplace has been recognized internationally, there is still a culture of silence in many institutions in the United States, perpetuating underreporting and insufficient and unproven interventions. The deliberate, repetitive, and aggressive behaviors of bullying can cause psychological and/or physical harm among professionals, disrupt nursing care, and threaten patient safety and quality outcomes. Much of the literature focuses on categories of bullying behaviors and nurse responses. This qualitative study reports on the experiences of nurses confronting workplace bullying. We collected data from the narratives of 99 nurses who completed an open-ended question embedded in an online survey in 2007. A constructivist grounded theory approach was used to analyze the data and shape a theory of how nurses make things rightwhen confronted with bullying. In a four-step process, nurses place bullying in context, assess the situation, take action, and judge the outcomes of their actions. While many nurses do engage in a number of effective yet untested strategies, two additional concerns remain: inadequate support among nursing colleagues and silence and inaction by nurse administrators. Qualitative inquiry has the potential to guide researchers to a greater understanding of the complexities of bullying in the workplace.Bullies And Incivility In Nursing Essay Paper

The situations are subtle and can range from sarcastic comments to being set up with the wrong patient chart… these sorts of things undermine your work day… erode your sense of comfort and security that you need to do your job in a professional manner (Nurse 41, 2007).

Given the stressful healthcare workplace, it’s no wonder nurses and other healthcare professionals sometimes fall short of communicating in respectful, considerate ways. Nonetheless, safe patient care hinges on our ability to cope with stress effectively, manage our emotions, and communicate respectfully. Interactions among employees can affect their ability to do their jobs, their loyalty to the organization, and most important, the delivery of safe, high-quality patient care.Bullies And Incivility In Nursing Essay Paper

The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements clearly articulates the nurse’s obligation to foster safe, ethical, civil workplaces. It requires nurses “to create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect” and states that “any form of bullying, harassment, intimidation, manipulation, threats, or violence will not be tolerated.” However, while nurses need to learn and practice skills to address uncivil encounters, organization leaders and managers must create an environment where nurses feel free and empowered to speak up, especially regarding patient safety issues.

All of us must strive to create and sustain civil, healthy work environments where we communicate clearly and effectively and manage conflict in a respectful, responsible way. The alternative—incivility—can have serious and lasting repercussions. An organization’s culture is linked closely with employee recruitment, retention, and job satisfaction. Engaging in clear, courteous communication fosters a civil work environment, improves teamwork, and ultimately enhances patient care.Bullies And Incivility In Nursing Essay Paper

In many cases, addressing incivility by speaking up when it happens can be the most effective way to stop it. Of course, meaningful dialogue and effective communication require practice. Like bowel sound auscultation and nasogastric tube insertion, communication skills can’t be mastered overnight. Gaining competence in civil communication takes time, training, experience, practice, and feedback.

The consequences of workplace bullying are as evident today as they were one hundred years ago. In 1909 Leon Harris condemned the treatment of nurses by their managers in an article published in The New York Times. Dr. Harris, citing multiple examples of workplace mistreatment, emphasized how “head nurses abuse their position of power” [1]. A century later the workplace has changed for the better in many parts of the world [2]. Yet, in spite of such advances, nurses still experience bullying in the workplace.Bullies And Incivility In Nursing Essay Paper

A problem in many healthcare institutions, workplace incivility is often referred to as bullying, lateral/horizontal violence, or harassment.1-3 It can be defined as “repeated offensive, abusive, intimidating, or insulting behavior, abuse of power, or unfair sanctions that make recipients upset and feel humiliated, vulnerable, or threatened, creating stress and undermining their self-confidence.”4Uncivil behaviors can range from lack of support to rude or humiliating comments, and may even include verbal threats.5 Determining the actual incidence and prevalence of workplace incivility is difficult because it’s often unrecognized and underreported.6 However, studies examining workplace incivility assert that the percentage of nurses experiencing some form of incivility ranges from 27% to 85% Bullies And Incivility In Nursing Essay Paper

Acts of incivility are devastating to nurses, affecting their performance, mental health, and intention to remain with an organization or even within the profession of nursing.5,6,8 Hospitals and healthcare organizations experience additional consequences from an uncivil work environment through increased costs related to nursing turnover, absenteeism, and decreased work performance.6According to one report, the average hospital will spend an estimated $379,500 for every percentage point increase in turnover rates.9 In addition, healthcare organizations spend an estimated $30,000 to $100,000 per year for each employee experiencing workplace incivility due to costs related to absenteeism, decreased work performance, staff treatment for depression and/or anxiety, and increased nursing turnover.6

Although the effects on nurses and healthcare organizations are clearly detrimental, a more dangerous consequence of incivility comes from its threat to patient safety. One study demonstrated a connection between incivility toward nurses and behaviors that may lead to compromised patient safety.10 The study included 130 nurses and delineated specific unsafe nurse practices that were directly related to instances of incivility. These unsafe practices included interpreting an unreadable order rather than asking for clarification, lifting or ambulating heavy patients without asking for help, and carrying out orders not considered to be in the best interest of the patient without challenging them.Bullies And Incivility In Nursing Essay Paper

In 2009, realizing that intimidating behavior affects morale, staff turnover, and patient care, The Joint Commission put standards in place that require leaders to maintain a culture of safety.11 According to The Joint Commission, organizations that fail to address unprofessional behavior are indirectly promoting such behavior. Uncivil behavior undermines the healthcare team’s effectiveness and can lead to medical errors and preventable adverse patient outcomes.12 Interventions aimed at reducing incivility in the workplace are beneficial to nurses, healthcare organizations, and patient Bullies And Incivility In Nursing Essay Paper

Workplace stress can influence healthcare professionals’ physical and emotional well-being by curbing their efficiency and having a negative impact on their overall quality of life. The aim of the present study was to investigate the impact that work environment in a local public general hospital can have on the health workers’ mental-emotional health and find strategies in order to cope with negative consequences. The study took place from July 2010 to October 2010. Our sample consisted of 200 healthcare professionals aged 21-58 years working in a 240-bed general hospital and the response rate was 91.36%). Our research protocol was first approved by the hospital’s review board. A standardized questionnaire that investigates strategies for coping with stressful conditions was used. A standardized questionnaire was used in the present study Coping Strategies for Stressful Events, evaluating the strategies that persons employ in order to overcome a stressful situation or event. The questionnaire was first tested for validity and reliability which were found satisfactory (Cronbach’s α=0.862). Strict anonymity of the participants was guaranteed. The SPSS 16.0 software was used for the statistical analysis. Regression analysis showed that health professionals’ emotional health can be influenced by strategies for dealing with stressful events, since positive re-assessment, quitting and seeking social support are predisposing factors regarding the three first quality of life factors of the World Health Organization Quality of Life – BREF. More specifically, for the physical health factor, positive re-assessment (t=3.370, P=0.001) and quitting (t=−2.564, P=0.011) are predisposing factors. For the ‘mental health and spirituality’ regression model, positive re-assessment (t=5.528, P=0.000) and seeking social support (t=−1.991, P=0.048) are also predisposing factors, while regarding social relationships positive re-assessment (t=4.289, P=0.000) is a predisposing factor. According to our findings, there was a notable lack of workplace stress management strategies, which the participants usually perceive as a lack of interest on behalf of the management regarding their emotional state. Some significant factors for lowering workplace stress were found to be the need to encourage and morally reward the staff and also to provide them with opportunities for further or continuous education.Bullies And Incivility In Nursing Essay Paper

As the toll of workplace bullying has become more widely known in all work settings, research has dramatically increased. Many North American studies focus on behavioral categories, causes, and typologies of individual responses [3]. There is limited information on how nurses experience and resolve workplace bullying. While bullying in the healthcare setting has been internationally recognized and researched [4, 5], many institutions minimize its impact or deny its existence, creating a culture of silence that impedes solutions to this problem [6–8]. While most individuals consider bullying to be a highly overt behavior, it is usually an insidious form of workplace aggression causing professionals to distance from each other fearing social exclusion or becoming the target of abuse. The consequences of bullying include compromised performance, job dissatisfaction, increased absenteeism, and staff turnover [4, 5, 9]. Newly graduated nurses are at significant risk as evidenced by higher resignation rates during the first year of practice [10–12].Bullies And Incivility In Nursing Essay Paper

Workplace bullying has also been acknowledged as a threat to patient outcomes and the delivery of quality of patient care, as well as the erosion of personal health and professional wellbeing [9, 13, 14]. Excellence in patient care flourishes in an environment built on open communication and respectful professional relationships. An environment that condones bullying perpetrates destruction of professional communication.

Bullying goes by many names: workplace aggression, indirection aggression, social or relational aggression, horizontal (lateral) violence, and workplace violence. It has become so popularized in the press; bullying is often, mistakenly, used as an overarching concept. There is a tendency to use many of these terms interchangeably [8]. Bullying is different from horizontal violence in that a real or perceived power differential between the instigator and recipient must be present [15]. Some of the most recent literature suggests that all of these behaviors exist on a conceptual continuum of workplace victimization [3].Bullies And Incivility In Nursing Essay Paper

Authors from different disciplines have contributed to the proliferation of constructs that label hostile workplace behaviors [16, 17]. Bullying is a contested concept. Instead of agreement on a universal concept and definition, authors have added to the challenges of building a relevant literature base and conceptual framework. Europeans have led research and policy advances in the field for over three decades. Swedish psychologist Heinz Leymann was the first to study workplace bullying in a systematic way, finding that these negative actions occurred frequently and over time, causing physical, emotional, and social consequences [18]. Others define bullying as repeated, offensive, abusive, intimidating, or insulting behaviors, abuse of power, or unfair sanctions [12, 19]. These negative social acts, not only occur repeatedly and regularly over time but also escalate and occur between individuals who have different positions of power [15]. Saunders et al. [20] suggest that the characteristics of negative actions and harm are the essential elements of bullying.Bullies And Incivility In Nursing Essay Paper

Scholars have underscored the importance of the durational characteristics of bullying [15, 21]. The dual dimensions of frequency and duration of bullying actions distinguish it from day-to-day social stresses or poor management styles in the workplace. Keashly and Jagatic propose that repetition is a principal characteristic of bullying; yet few studies have explored the repetitive experience of bullying, either by frequency, duration, patterns, or escalation [17].

The relationship between negative psychological consequences and workplace bullying is well established [3]. In addition to the emotional and cognitive effects, there are physiological consequences [13]. Recipients of bullying feel humiliated, vulnerable, or threatened, thus creating stress and undermining their self-confidence [12, 19].Bullies And Incivility In Nursing Essay Paper

Prior to the last ten years, the nursing literature leaned towards anecdotal reports or articles suggesting practical solutions for dealing with workplace bullying [22]. Outside of nursing, research has been conducted using quantitative studies, primarily prevalence surveys. This complex phenomenon may require qualitative approaches for a fuller explication [23]. Such methods will allow us to unearth the interaction of individual, organizational, and cultural factors that enable, trigger, and reward bullying [6]. To this end, workplace bullying must be seen as a social process, “in which the impact on the person experiencing it is of primary importance” [24].

This qualitative study was part of a larger survey whose purpose was to validate the occurrence and patterns of bullying among nurses in the US [8]. The second-level qualitative analysis of the nurses’ narratives describing their bullying experiences in health care settings is presented in this paper. We specifically sought to understand how nurses encounter bullying in the workplace and the strategies they use to protect themselves and their patients.Bullies And Incivility In Nursing Essay Paper

The approach adopted for this qualitative study was based on constructivist grounded theory methods [25, 26]. Charmaz contends that theory emerges not solely from the data but in concert with the individual experiences of the participants as well as values and experiences of the researcher [25, 26]. In a constructivist approach, the central question addresses how social reality is constructed. In addition, the researcher seeks to identify the elements of that reality [27]. To that end we were guided by both questions. First, we wanted to know how the social reality of bullying in the workplace came together for nurses and second what are the elements and organization of their reality. Working back and forth between these two questions throughout the analysis allowed us to make visible important aspects of the nurses’ world and understand their experience of bullying. In a constructivist approach, Charmaz [25, 26] suggests that data and its analysis are social constructions leading us to ask what is the purpose of the narratives and how does the setting influence the phenomenon?Bullies And Incivility In Nursing Essay Paper

Whether you’re an ICU nurse dealing with life-or-death situations, a social worker counseling clients through traumatic events, a pharmacist faced with prescription quotas or another type of healthcare worker coping with your own pressures, learning to handle stress is critical to managing your healthcare career.

Ongoing stress can manifest itself in a host of physical and psychological symptoms, including headaches, sleep disturbances, poor concentration and depression. Research suggests that high stress levels may impair the immune system and increase the risk of cardiovascular disease and cancer.Bullies And Incivility In Nursing Essay Paper

Complete objectivity is not possible by the researcher, “constructivist grounded theory assumes relativity, acknowledges standpoints and advocates reflexivity” [28]. Researchers bring their own values, experiences, and biases to the research process. Examining the relativity of perspectives, positions, practices, interactions, and the research situation is crucial to the process. With Charmaz’s premise in mind, we acknowledge that the members of our research team come from different viewpoints to understand bullying in the nursing workplace. The diversity of our perspectives and experience are convergent, not biasing our approach. Our values and experiences complement one and other, allowing us to see the perspectives of the participants through different lenses. Our reaction to workplace bullying particularly in the health care setting and specifically among nurses was consistent. It was precisely our own workplace experiences and listening to the stories of nurses that brought us to formally investigate this problem.Bullies And Incivility In Nursing Essay Paper

Markham states, “an ethical researcher is a reflexive researcher who works from the heart” [29]. Being reflexive throughout the research process focused us on understanding how we contributed to the construction of meaning. Repeatedly, we stopped at critical junctures and explored why and how we came to an interpretation or a particular decision. This required a constant vigilance in rediscovering and sharing our own values, interests, politics, and even the influence we had on each other.

Because we conducted the study in a virtual setting, we thought a great deal about our respondents, who they are, and where they worked. Our participants existed both online and offline, and we reflected on their location within those worlds, a connected space of sorts [30]. We also understood the possibility that what happens in the online world is interwoven with the offline real world; there can be mutual shaping of the two [31]. Within the communication context, there is an interaction of the encounter and the virtual space [31].Bullies And Incivility In Nursing Essay Paper

Unprofessional behavior among clinicians adversely affects patient safety and the quality of care. This literature review sought to apply a systems approach to studies of workplace civility in nursing. The included studies demonstrated that rude behavior is perceived to diminish care quality, increase risk of adverse events, and worsen patient satisfaction. Researchers identified triggers for workplace incivility, such as negative organizational climate and power imbalances, as well as consequences including low self-esteem and decreased productivity. The authors note that high stress environments can foster incivility and lead to burnout. They recommend practice-based competency in civility in order to improve patient safety. A previous PSNet perspective discussed how to identify and manage problem behaviors.Bullies And Incivility In Nursing Essay Paper

Permission to conduct the study was obtained from the institutional review board (IRB) at a large university in the state of Massachusetts.

An Internet web link to a 30-item anonymous e-survey was created [32] and appended to an article about workplace bullying in Nursing Spectrum a hard-copy and web-based, free, biweekly nursing magazine [33]Consent to participate was affirmed by respondents completing the online survey and posting the optional narrative. The respondents were anonymous and not matched to the data of the larger quantitative study [8]. The optional question in the online survey was offered to participants as follows, “If you would like, in the space below please describe the bullying situation as you remember it. Please refrain from using any identifiable data (e.g., names, specific hospital, etc.).” The Internet web link was open for participant responses for a three-month period.Bullies And Incivility In Nursing Essay Paper

A total of 99 narratives were submitted through the online survey and downloaded into Microsoft Word. Eleven responses were removed from analysis because the respondent offered commentary, broad generalizations, or opinions. Another six narratives were removed from analysis because they met the US Equal Employment Opportunity Commission definitions of harassment (sexual, disability, racial, or national origin) [34]. One narrative was removed because a nurse did not write it. A total of 81 narratives, ranging from five words to 780 words, were analyzed. Some narratives were very brief, “it is too painful to talk about,” while others wrote several hundred words describing who, what, when, where, how, and the consequences of working in a hostile environment.

Prior to open coding, we performed preliminary readings to capture the tone of each narrative and become attuned to the text, allowing us to gain a holistic understanding of the respondents’ experiences before further analysis.Bullies And Incivility In Nursing Essay Paper

Charmaz’s [26] approach to coding is multilayered. To optimize our sensitivity and carefully attend to the nurse’s perspectives, we first coded narratives as a team and later, the first author led continued coding. We used the constant comparative method [35] to make comparisons at each level of our analysis looking for similarities and differences. We began with open coding (line by line) allowing us to look closely at the responses and reflect on the substance of the narratives. In some cases the nurses’ words provided initial code names (in vivo codes). During the second phase we began focused coding by taking the most significant and frequently occurring earlier codes to sort through the data. The next step allowed us to identify linkages and connections. We developed categories by clustering similar codes, and from those categories we generated hypotheses about how the categories were related. We then moved to the discovery of a core social process [36]. We used theoretical coding to integrate the emerging theory. Theoretical coding allowed us to go beyond description and specify properties of and relationships between categories. We used Charmaz’s analytic categories of agency, action, power, networks, and narrative and biography to further investigate the data at the stage of theoretical coding [26]. Throughout each phase of this process, we wrote memos, conferred with each other, and reached agreement on codes, categories, and concepts. We revisited the text of the nurses’ responses throughout the analysis.Bullies And Incivility In Nursing Essay Paper

Causes of Incivility in Nursing
A perceived power imbalance is most often a requisite to bullying. Bullying appears to be particularly prevalent in institutions where hierarchy and power imbalances are strongly emphasized (Salin, 2003). Nursing was founded as a predominantly female profession in a patriarchal society with a cultural standard of gender oppression (Bartholomew, 2006). Additionally, in Western healthcare, nursing is practiced in a medically-dominant environment, where work structures are traditionally hierarchal in nature. Patients are admitted under the treating physician’s name and nameless nurses will execute physician’s orders. Furthermore, the organizational model of nursing is derived from historical roots in the military. This hierarchal system is thought to place nurses in a position of inferiority of rank and subordination. Literature supports the subordinate role of nurses, finding that nurses lack autonomy, control, and self-esteem (Freshwater, 2000). As a result, nursing has been described as a culture characterized by obedience, servitude, dedication, and adherence to hierarchy (Hutchinson, Vickers, Jackson, and Wilkes, 2010).Bullies And Incivility In Nursing Essay Paper

Uncivil behavior among nurses is posited to result from this culture of oppression and subordination. Horizontal violence and incivility was originally described as an internal manifestation of conflict that resulted from oppression of one group by a more powerful entity (Freire, 2000). An oppressed group is one in which members lack power or control except within the group itself (Peters, in press). Internalized beliefs about their own inferiority prevents the oppressed group from controlling their own destiny, maintaining the status quo and allowing power structures to remain unchallenged. Frustration with these feelings results in aggression toward colleagues within the oppressed group (Hutchinson, Vickers, Jackson, & Wilkes, 2005). Members of the oppressed group direct their frustrations toward each other as they cannot act out directly to those who create the oppression (Freshwater, 2000). From this perspective, incivility in nursing is the reaction to the oppression and subordination experienced by nurses as a collective profession.Bullies And Incivility In Nursing Essay Paper

Besides a culture of oppression, the socialization of nurses into the profession is said to propagate a culture of incivility. Foundational paramilitary influences are said to have fostered a culture in which insult, humiliation, and hazing are considered part of the on-the-job training (Hutchinson et al., 2005). In fact, the metaphors frequently used in nursing orientation include “earning one’s stripes” and “boot camp”. A common narrative is to intentionally subject a novice nurse to the same experience seasoned nurses had when they entered practice, with the mentality of “if I had to do it, (s)he can too” (Bartholomew, 2006). Compounding the problem is that most females have been socialized not to react to conflict, to avoid it, and to keep the peace. Nurses too have been socialized not to assert themselves individually or collectively. The result is that nurses often are silent as either targets or witnesses of incivility (Croft & Cash, 2012).Bullies And Incivility In Nursing Essay Paper

Students and new graduates are particularly at risk to be targets of incivility. In Freire’s theory of oppression, any member introduced into a powerless group is at high risk for horizontal violence (Freire, 2000). Additionally, Kanter’s Structural Theory of Empowerment finds that when subordinates try to assert their power and authority, only to have it blocked, they usually will seek power over those whom they can dominate. Usually that power is directed downward in the hierarchy (Twale & De Luca, 2008). Incivility is used to acculturate new members into the oppressed group; it is how the unspoken rules are taught (Bartholomew, 2006). Targets of incivility are usually individuals who are different or threaten the status quo (Salin, 2003; Twale & De Luca, 2008). If the status quo is disrupted, fear escalates within the group and is expressed as hostility. Until the newcomer is acculturated as a subordinate group member he or she is considered a threat and treated as such (Bartholomew, 2006). Victims often have done something unknowingly to disrupt the status quo that results in hostility. These acts may range from simply being hired to questioning a philosophy or process of a seasoned organizational member. If someone is introduced to the culture who does not adhere to the group expectations, or worse, challenges the dominant members or cultural norms, they are eliminated, treated uncivilly, bullied, taken advantage of, or marginalized (Twale & De Luca, 2008). As is often heard, the notion of “nurses eating their young” continues to prevail in contemporary nursing.Bullies And Incivility In Nursing Essay Paper

More recent literature has considered contextual factors such as job conditions, levels of empowerment and the presence of in-groups as explanations for incivility. While some organizational factors have been explored, no studies in any setting involving nurses are found that explore the relationship of the leadership style of a nurse leader with perceived levels of incivility. It is well established that leaders have a profound impact on the culture and interpersonal relationships of a group. A potential explanation for uncivil behaviors that has been little explored is the impact of leadership style on nurse-to-nurse incivility.Bullies And Incivility In Nursing Essay Paper

Organizational Culture
In the nursing literature, incivility has been predominantly understood as the reactions of an individual agent within a subordinate group exhibiting oppressed group behavior. Oppressed group explanation of incivility provides one consideration, but is not the only factor that impacts incivility in nursing (Hutchinson et al., 2005). Organizational issues contribute to an environment in which incivility is normalized and acceptable. The assumption that incivility is simply a result of the unique socialization of nurses as a subordinate group fails to consider the organizational contexts in which nurses work, as well as the organizational factors that impact incivility (Hutchinson et al., 2005). “Organizations and management structures have been able to remain immune from any further consideration as to their role in perpetuating bullying” (Hutchinson et al., 2005, p. 120).Bullies And Incivility In Nursing Essay Paper

Organizational culture influences how members perceive their interpersonal interactions and how they manage and respond to such interactions (Keashly & Neuman, 2010). An organization that encourages genuine friendships will have a more positive atmosphere. An organization that promotes boundaries and professional distance may have respectful interactions, but may fall more easily into incivility in times of stress or conflict. Lateral violence has been described as an emotion-based response triggered by factors such as rapid change, pressures for increased productivity, and chaotic work environments (Hutchinson et al., 2010).Bullies And Incivility In Nursing Essay Paper

Workplace demands are thought to create pressures and opportunity for incivility. Hutchinson et al. notes that contemporary “healthcare organizations are now characterized as transactional climates, strongly focused on productivity and its reward” (2010, p. 27). The central pressure within healthcare organizations is cost containment, with organizational goals described in terms of efficiency and quality. Nurses are under constant surveillance and are challenged daily with providing care in a corporate context (Hutchinson et al., 2005). This added pressure and scrutiny compounds the already complex environments in which nurses work, including a frantic pace, high-stake decisions, and heavy workloads. This type of environment induces frustration and high emotions (Croft & Cash, 2012). The effects of stress contribute to the use of incivility as a reaction to the environment.Bullies And Incivility In Nursing Essay Paper

In some organizations, incivility is more or less permitted as the way things are done. There exist organizations in which bullying is actually considered acceptable and creates advantages to the perpetrators (Salin, 2003). Furthermore, it is suggested that uncivil behavior amongst nurses is ‘accepted’ within the profession as part of the metanarrative (Hutchinson et al., 2005), i.e. “nurses eat their young.” Often in nursing units, cliques with nursing management and select staff are formed, and this group dictates the norms of the unit. Self-assured of their position in the alliance, these nurses act to enforce the ‘rules of work’ (Hutchinson et al., 2010). It has been found that bullies within the nursing workforce in particular are often protected by those in power (Croft & Cash, 2012).Bullies And Incivility In Nursing Essay Paper

The Corollary Role of Leadership
The leader of an organization has a powerful influence on organizational culture. The important role of leadership and organizational structures in influencing a positive workplace is well-documented. In a workplace with a strong sense of team membership and community, incivility is much less likely (Clark & Springer, 2010; Weaver Moore et al., 2013). Leaders are powerful role models, and their actions communicate messages as to what is considered acceptable behavior (Clark, Olender, Kenski, & Cardoni, 2013). Leaders play a key role in establishing the climate and culture of the organization. Ultimately, people are more likely to follow the performance cues of those with social power or social status within an organization (Twale & De Luca, 2008). Organizational culture includes the norms, values, and rituals that characterize an organization, and “serves as a social control mechanism that sets expectations about appropriate attitudes and behaviors of group members, thus guiding and constraining their behaviors” (Bally, 2007, p. 144.). It is vital to identify the effect of leadership and organizational culture on uncivil behaviors among nurse coworkers.Bullies And Incivility In Nursing Essay Paper

Incivility in the workplace has far-reaching, damaging effects to both the individual and the organization. Incivility is a particular problem in the nursing profession, which, paradoxically, is founded on caring. Leaders can play a key role in attenuating or contributing to levels of incivility. Hence, it is important to first understand what particular leadership styles or behaviors are more or less associated with worker incivility. From this information, actions by the leader to prevent workplace hostility can be better implemented.Bullies And Incivility In Nursing Essay Paper

Experiencing incivility in today’s society is a relatively common occurrence. When faced with it, most people tend to try to just shrug it off, not taking too much offense to it, and definitely not confronting the problem. Although this may not seem like too much of an issue, studies have shown that incivility causes a variety of individual, social, and organizational problems.
One way the individual faces such rudeness is on the Internet. Many people are much more willing to abandon their obligation to be polite when sitting behind their computer, especially when the website includes the user’s anonymity (Clay). One study shows that individuals who frequent websites in order to argue, rant, or vent actually tend to “score higher on anger measures, express their anger more maladaptively and experience such negative consequences as verbal and physical fights more frequently than others” (Clay). Although this statistic may be true, correlation cannot be used to find causation. It very well may be that people who already have anger problems might be the ones frequenting these websites, and their anger problem is the reason they are frequenting the websites instead of the websites causing the anger problem. Bullies And Incivility In Nursing Essay Paper
A social issue regarding the effect of incivility is the constant use of cell phones. When in public, people who are on their cell phones may be “so wrapped up ‘in their own little bubbles’ that they don’t even realize they’re blocking a sidewalk or holding up a line” (qtd. in Clay). This phenomenon is due to the fact that a human’s attention has a limited capacity and a selective nature (based on the research of Hermann von Helmholtz) and therefore, when their attention is on their phone the overall attitude of the hospital staff being changed, and when the new hires entered in, they, through observational learning from the more experienced staff, acquired the favorable work attitude.
Incivility can affect many different aspects of our lives. A few are causing anger problems, being in others’ way, making it difficult for somebody to concentrate, and causing workers to skip work. However, at least in the workplace, this issue can be helped (if the company is willing). Although on a small scale, incivility and rudeness may seem insignificant, they have proved to be quite problematic.Bullies And Incivility In Nursing Essay Paper

Many definitions of workplace bullying are cited in the literature. In the Australian context, a broadly accepted definition is that provided by the Australian Human Rights Commission (2013)), who define workplace bullying as “verbal, physical, social or psychological abuse by your employer (or manager), another person or group of people at work”. In Australia, the incidence of bullying has risen to 6.8% (Dollard et al., 2012).

Bullying, incivility, vertical and horizontal violence are not new phenomena in the nursing profession. Nursing has long been known for its culture of bullying practices, often described as “eating our young” (Meissner, 1986). Nurses worldwide acknowledge uncivil behaviour as commonplace in the profession. Research clearly demonstrates high levels of nurses experiencing and witnessing bullying. The actual level of bullying is difficult to determine; various studies report the incidence of bullying to be as high as 72% in nursing, with other studies citing figures around 50% (Berry, Gillespie, Gates, & Schafer, 2012Farrell & Shafiei, 2012Spector, Zhou, & Che, 2014).Bullies And Incivility In Nursing Essay Paper

The consequence of bullying in the workplace includes negative effects on physical and mental health of the individual (Bardakci and Gunusen, 2014D’Ambra and Andrews, 2014) leading to attrition from the nursing profession (Weaver, 2013). Bullying affects the person being bullied and their colleagues, contributing to workplace errors and concerns for patient safety (Bennett and Sawatzky, 2013Etienne, 2014) with nursing students reporting various feelings such as fear and embarrassment (Tee, Üzar Özçetin, & Russell-Westhead, 2016).Bullies And Incivility In Nursing Essay Paper

Reports of nursing students experiencing bullying have become prevalent more recently in the literature. An Australian study (Hopkins, Fetherston, & Morrison, 2014) of 153 second and third year baccalaureate nursing students reported over half (57%) had experienced some form of non-physical violence. About a third of second-year and 25% of third-year students had been victims of physical attacks such as being punched or kicked during their time on clinical placement. Disappointingly, the reports are unchanged over time and distance. In 2011, more than a third of Italian nursing students reported having been exposed to at least one episode of workplace violence (Magnavita & Heponiemi, 2011). A study from Egypt found that 38% of nursing students experienced a moderate degree of bullying (Kassem, Elsayed, & Elsayed, 2015). A similar incidence (42%) was recently reported by UK nursing students (Tee et al., 2016).

While the studies discussed here demonstrate the unchanging prevalence of bullying, little is known about the experiences of Australian students in the clinical setting, which is where a significant component of their baccalaureate program is undertaken. As part of a larger study investigating the nature and extent of bullying experienced by students on clinical placement, this paper aims to describe these experiences as told by the participants in their own words.Bullies And Incivility In Nursing Essay Paper

This study employed a cross-sectional survey that was delivered online via the Survey Monkey platform. All students enrolled in baccalaureate nursing degrees in Australia were eligible to participate in the study. Following approval from the university’s Human Research Ethics Committee, Heads of Schools of Nursing were contacted via the Council of Deans of Nursing and Midwifery and asked to disseminate the survey link to their students. Participation was voluntary and submission of the survey indicated consent for use of the data. Participants could refuse to answer any or all of the questions.

The original survey tool was produced by Hewett (2010)) who developed the instrument for her study of 218 undergraduate nursing students in South Africa. To ensure relevance to the local context, terminology used throughout the tool was adapted and a number of items were added. The revised instrument (Student Experience of Bullying During Placement (SEBDP) survey) (Budden, Birks, Cant, Bagley, & Park, 2015) consisted of 10 questions that sought demographic data, followed by a total of 83 items about experiences of bullying and/or harassment over 13 sections. Most questions used a frequency response scale of [1] ‘Never’ (0 times); [2] ‘Occasionally’ (1–2 times); [3] ‘Sometimes’ (3–5 times) and [4] ‘Often’ (>5 times). While the adapted version of the tool included an important early question asking whether students had been bullied or harassed, no actual definition of bullying or harassment was included in the survey to avoid leading respondents. Numerical and categorical data were analysed using inferential statistical tests. These findings have been presented elsewhere (Budden et al., 2015).Bullies And Incivility In Nursing Essay Paper

This paper reports on the textual data provided by participants throughout the survey and in response to a final question that asked whether they had any further comments to make about bullying and harassment of nursing students on clinical placement. Participants were given the option of adding these comments in order to clarify or illustrate their responses. These data were significantly greater than expected in terms of both quantity and richness. It was clear from the breadth and depth of these data that the students welcomed the opportunity to share their stories.

An inductive thematic analysis, employing an approach consistent with that described by Jirojwong, Johnson, and Welch (2014)) was used to analyse the data. This process involved coding the qualitative clarifiers or comments provided during the survey and subsequently collapsing these into themes. This approach permitted a condensed and broad description of bullying and harassment in the clinical environment using the words of the participants. Thematic analysis facilitated categorisation of a large amount of textual data, distilling words into fewer content-related themes.Bullies And Incivility In Nursing Essay Paper

Regardless of what we call it, incivility, bullying and/or lateral violence exists in nursing and we need to figure out how to end it. Unfortunately, the problem can be found in nurses working across all areas of practice. Perhaps most damaging is the fact that nurses have been role modeling this behavior in full view of student nurses (the future stewards of our profession!)

While nursing is a profession dedicated to helping others, the highly charged nature of many of the environments in which nurses work can lead to situations where emotions boil over.

Incivility, bullying, and violence in the workplace are serious issues in nursing, with incivility and bullying widespread in all settings. Incivility is “one or more rude, discourteous, or disrespectful actions that may or may not have a negative intent behind them”. ANA defines bullying as “repeated, unwanted, harmful actions intended to humiliate, offend, and cause distress in the recipient.”Bullies And Incivility In Nursing Essay Paper

Such acts of aggression – be they verbal or physical – are entirely unacceptable, whether delivered by patients or colleagues. These incidents not only have a serious effect on the wellbeing of the nurse in question but also their ability to care for their patients.

ANA seeks to protect nurses from all types of workplace conflict through various methods including advocacy, policy, and resources. We want nurses, employers, and the public to jointly create and nurture a healthy, safe, and respectful work environment in which positive health outcomes are the highest priority.Bullies And Incivility In Nursing Essay Paper

According to The National Institute of Occupational Safety and Health (NIOSH), there are four types of violence that nurses might face in their work environment:

  1. Criminal Intent. The perpetrator has no relationship with the victim, and the violence is carried out in conjunction with a crime.
  2. Customer/client. The most common health care environment-based assault, the perpetrator is a member of the public with whom the nurse is interacting during the course of their regular duties.
  3. Worker-on-worker. Commonly perceived as bullying, in these instances the perpetrator and victim work together – though not necessarily in the same role or at the same level.
  4. Personal relationship. In these incidents, the victim has been targeted as a result of an existing exterior relationship with the perpetrator, with the violence taking place in the workplace.Bullies And Incivility In Nursing Essay Paper

It is important to remember that none of the scenarios above are restricted to physical violence – verbal and psychological abuse can be just as damaging to both the nurse and their ability to care for patients. All such abuse comes within the scope of ANA’s anti-workplace violence agenda.

In a 2006 survey conducted by the American Association of Critical-Care Nurses (AACN), 24.1% of respondents stated they had been verbally abused by a peer (Luparell, 2011). This is not a phenomenon exclusive to the nursing profession; research shows that all professions are experiencing an increase in incivility. In a January-February 2013 Harvard Business Review article, researchers found that 98% of respondents, including lawyers, architects, coaches and physicians, reported experiencing uncivil behavior at work (ANA, 2016).Bullies And Incivility In Nursing Essay Paper

Incivility is the behavior of ignoring and being contemptuous at others creating an atmosphere filled with rivalry, stress, and disrespect (Smith, Carpenter & Fitzpatrick, 2015). Nursing incivility has gained great interest to many researchers due to its emerging challenge in the field of education and working environment posing a severe impact on the vulnerable population. These uncivil behaviors among learning institutions and health centers have been seen to disrupt progress not only to nursing students, professional practitioners, hospitals but also to patients’ health. This study, therefore, intends to recognize and address the effects of nursing incivility on nursing education and workplace surroundings.Bullies And Incivility In Nursing Essay Paper

Effects of Incivility on Nursing Education and Workplace Environment

Historically, the term ‘nurse ‘calls for respect, kindness, and honesty (Clark & Sigma Theta Tau International, 2013). However, in recent years incivility in nursing education and to peers has garnered much growth which consequentially has resulted in physiological and psychological distress. In return, this issue has led to various implications for patients, nurses and health care organizations. These unethical actions used by nurses include bullying which refers to abuse of power, insulting behaviors, repeated abuse, and intimidation; or unfair deeds that make recipients feel humiliated and endangered thereby causing distress and little self-confidence. Other vices include sabotage, innuendo, confidence breakage, withholding information, in fights, disrespecting one’s privacy and verbal affronts.Bullies And Incivility In Nursing Essay Paper

Incivility in nursing schools and the clinical setting exist in the form of learners bullying each other, faculty members bullying other teachers and students bullying teachers and vice-versa. Although incivility is experienced in most professionals, the difficulty seems eminent in the clinical nursing setting. Over the years research investigating workplace incivility provided an estimate that prevalence extents are between seventy-five and one hundred percent. This means that all employees to a certain degree have experienced some level of incivility from their colleagues, peers or patients. In a survey conducted it was found that more than 4,000 critical care nurses that are 18%, experienced verbal abuse from their co-workers (Smith, Carpenter & Fitzpatrick, 2015). Approximately 25% rated the quality of collaboration among registered nurses as fair or poor while 22% rated respect for other clinicians as fair or poor (Smith, Carpenter & Fitzpatrick, 2015).Bullies And Incivility In Nursing Essay Paper

According to totally 70% of nurses who were victimized in the process left their jobs, ironically, a third of those with health difficulties left their jobs due to those problems. Roughly 60% of the new rated nurses resigned in half a year of being insulted and a third fresh of graduates’ nurses considered quitting from their workplaces altogether due to humiliation and offensive encounters. Clark & Sigma Theta Tau International (2013) shows that the victims tend to react against one another since they are not capable of handling their situations. Their frustrations limit their speech and ability to express their feelings and grievances lowering their self-esteem hence causing chaos and inadequacy of teamwork support. Most oppressive conditions, for example, limited staffing ratios; administrative hierarchies have promoted minimum recognition, inadequate supplies and denial of uninterrupted breaks by nurses.Bullies And Incivility In Nursing Essay Paper

This toxic work atmosphere makes victims feel invisible, inferior, incompetent and isolated from the other teams eventually subjecting them to psychological and occupational imperialism. Research on bullied clinicians in the United States revealed that workplace incivility accounts for a third to one-half of stress-related absenteeism. In Canada, one in seven deaths results from workplace bullying (Smith, Carpenter & Fitzpatrick, 2015). Uncivil behaviors have eroded work contentment and morale, in turn, lowering productivity and quality, increasing absenteeism and promoting high staff turnover. With the high cost of hiring and orienting new protectionists’, losing nurses within the first working term creates an enormous financial burden on the organization. Low job satisfaction also reduces patients’ contentment thus affecting reimbursement and patients’ attempt to recommend the institution (Clark & Sigma Theta Tau International, 2013). It is also evident that these unethical acts pose a threat to patient safety by interfering with communication, teamwork, and cooperation. These victims tend to be reluctant to ask questions and to speak up to advocate for patients; endangering patients’ safety and outcome by ignoring to offer assistance needed paving the way for fatal health errors to occur. The high turnover of nurses caused jeopardizes progression on the unit denying fresh nurses experience and knowledge to detect and respond quickly to potential patient problems.Bullies And Incivility In Nursing Essay Paper

The increase in incivility has resulted in the American Nurses Association (ANA) revising the Code of Ethics for Nurses with Interpretive Statements to state that nurses are required to “create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect. Similarly, nurses must be afforded the same level of respect and dignity as others. Thus, the nursing profession will no longer tolerate violence of any kind from any source. All registered nurses and employers in all settings, including practice, academia, and research must collaborate to create a culture of respect, free of incivility, bullying, and workplace violence. Best practice strategies based on evidence must be implemented to prevent and mitigate incivility, bullying, and workplace violence; to promote the health, safety, and wellness of registered nurses, and to ensure optimal outcomes across the health care continuum. This position statement, although written specifically for registered nurses and employers, is also relevant to other health care professionals and stakeholders who collaborate to create and sustain a safe and healthy interprofessional work environment. Stakeholders who have a relationship with the worksite have a responsibility to address incivility, bullying, and workplace violence” (ANA, 2015).Bullies And Incivility In Nursing Essay Paper

Additionally, in 2010, The Joint Commission (TJC) implemented new standards to require healthcare organizations to have mechanisms in place to deal with incivility, and the AACN developed standards for a healthy work environment. But despite these initiatives, incivility in healthcare has remained a persistent problem.

Reversing this behavior isn’t all that difficult. Start with yourself: Be responsible for your behavior. Be proactive in your work environment. Role model the kind of nurse you would want in the workplace, with the behaviors you would expect from a healthcare professional. Remember the GOLDEN RULE: “Do unto others as you would have them do unto you.”Bullies And Incivility In Nursing Essay Paper

At the same time, help develop a culture of zero-tolerance when it comes to incivility. Reinforce those lessons with education regarding effective communication, setting up boundaries, identifying acceptable behavior, and finally holding the offender accountable fairly and equitably. This is not about blame, but accountability for one’s own actions.

Some would argue that the nursing profession demands more from its nurses than it gives. Working 12-hour shifts, coping with trauma, managing multiple complex patients while often short-staffed, working without adequate meal breaks, and comforting heartbroken family members is only the tip of the iceberg for hospital-based nurses.

Nurses often seem to do their work effortlessly despite how complicated their jobs really are. Nurses have a sense of grace, selflessness, and compassion that society has come to expect from these caregivers. To illustrate the profession’s standing, nurses have ranked as the most trustworthy professionals for the last 15 years in Gallup’s annual poll of Honesty and Ethical Standards in Professions.Bullies And Incivility In Nursing Essay Paper

Unfortunately, despite the stellar reputation that they enjoy, there is a hidden culture of nurse hazing, bullying, name-calling, and disruptive behavior on hospital units throughout America. Bullying, which the American Nurses Association (ANA) defines as “repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient,” is an extremely serious issue that threatens patient safety, nurse safety and sanity, and the reputation of the nursing profession as a whole.

Any nursing student has heard the phrase, “nurses eat their young,” which was first used by nursing professor Judith Meissner in 1986; the expression has become standard lore among nurses. The meaning behind it is quite simple: simply, it refers to the bullying and harassment of new nurses, and  those four simple words can cause a great deal of anxiety for new graduates. In fact, researchers propose that at least 85% of nurses have been bullied at some point in their nursing career.Bullies And Incivility In Nursing Essay Paper

A study done in conjunction with Vanderbilt University Medical Center shows that approximately 60% of new nurses leave their first position within six months due to some form of verbal abuse or harsh treatment from a colleague. While most nurses will not disclose this information during exit interviews with their employers, they speak freely when reporting  anonymously. The U.S. Bureau of Labor Statistics projects a shortage of 1.05 million nurses by 2022; unfortunately, as more studies and information are released regarding nurse bullying and harassment, the risk is that the number of those entering the nursing profession could dwindle.Bullies And Incivility In Nursing Essay Paper

This topic isn’t new to the nursing profession. Numerous research studies have speculated regarding why this trend has yet to be broken. In 2007, nurse researchers Cheryl Woelfle and Ruth McCaffrey published a studywhich discusses why nurses attack their own. Based on interviews and surveys, it was determined that “nurses often lack autonomy, accountability, and control over their profession.” Unfortunately, due to this lack of control, “this can often result in displaced and self-destructive aggression within the oppressed group.” While nurses admit to bullying in this survey, it seems it is only discussed in private confidential forums. It is difficult to find many nurses who will speak openly and freely about bullying for fear of negative personal and professional ramifications.Bullies And Incivility In Nursing Essay Paper

An interesting fact about nurse bullying is that it is considered a form of “horizontal violence”, also known as “lateral violence”; however, managers rarely take action when bullying is present. At a prominent children’s hospital on the east coast, a nurse spoke about her ICU experience anonymously for fear of backlash.

“When I first started as an experienced nurse, but new to the (current) hospital, more senior nurses would call me names and question my abilities in front of patients,” she stated. She was quick to note that she actually had more experience than these “senior nurses” but was still considered a newbie. She goes on to say, “I spoke to my manager several times as well as the director of the ICU because there was a very clear hospital policy against nurse bullying. Ultimately, nothing was done and I was given the choice to deal with it or transfer to another unit.”Bullies And Incivility In Nursing Essay Paper

After much consideration, she decided to stay on her unit and worked hard to be a positive role model for other staff members. While the changes on her unit will take time and may be very small and incremental, she is optimistic that the culture can change. Bullies And Incivility In Nursing Essay Paper

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