It’s time for a critical culture change in nursing—from powerlessness to partnership.

We’ve talked before about the cultural challenges that face nurses in their work environments. But if key decision makers don’t implement real change, it can be nearly impossible for a culture that foments incivility and disruptive behavior to evolve and improve. The unchecked risks in such a culture merely fuel more adverse outcomes among staff and patients. Collaboration is the key to breaking this long-standing dysfunction within the healthcare system—and it’s the only way to create safer, healthier work environments for nurses.
Collaboration is the key to breaking long-standing dysfunction within the healthcare system—and it’s the only way to create safer, healthier work environments for nurses.

What does “civility” really mean? Safety.

Within the scope of nursing, the terms “civility” and “incivility” plunge well beyond the surface of professional etiquette. Behaviors can range from discourtesy to assaultive behavior—in staff, patients, or their families. So it’s critical to establish and nurture a culture of safety as part of any workplace civility training within the nursing profession, because the entire hospital—particularly its patients—will benefit just as much as nurses do.
A lack of civility in health care leads to real, and sometimes deadly, consequences. The Online Journal of Issues in Nursing (OJIN), a scholarly journal of the American Nurses Association, has shared their findings that, “Disruptive behaviors threaten patient wellbeing due to a breakdown in communication and collaboration.” They cited a survey of 4,539 healthcare workers that found:
  • 67% of heath care workers perceive a link between disruptive behavior and adverse events
  • 71% of health care workers perceive a link between disruptive behavior and medication errors
  • 27% of health care workers perceive a link between disruptive behaviors and patient mortality
The authors of the article also referenced a second study that illustrated how the adverse outcomes of disruptive behavior can cause unique harm to specialized departments—for example, more than half of the respondents in a survey regarding disruptive behavior in obstetrics felt that such incidents contributed to near misses in their labor and delivery unit.
We can’t let semantics get in the way of sustaining truly safe Environments of Care. “Incivility in the workplace” might sound like clinical terminology, but it’s the root of behavior that can lead to incredible harm.

Let’s talk about what’s really happening to nurses. Workplace violence.

Here at CPI, we’ve defined workplace violence as a continuum of behaviors that include the following:
  • Discourtesy
  • Disrespect
  • Intimidation
  • Harassment/Bullying
  • Retaliation
  • Verbal Assault
  • Physical Aggression
You can immediately see that “violence” spans everything from incivility to assaultive behavior, because disruptive behavior is a product of escalation—it doesn’t happen in a vacuum. If you work in health care, you’ve seen these behaviors before, likely with staff and with patients. When you view violence as a holistic concept, it’s immediately clear how seemingly trivial things transmogrify into big ones—it may start with one incident, but can threaten the Care, Welfare, Safety, and Security of your entire organization.
Ignoring minor incivilities unwittingly amplifies the potential for workplace violence—so we must acknowledge that violence is a systemic problem and address it comprehensively. This means going beyond just educating staff about the risks of harm, and empowering them to safely intervene and even prevent risk behaviors before they escalate irreversibly.
Decision makers can’t afford to wait. Within the next four years, more than half a million experienced nurses will retire. This leaves a projected need for approximately 1.1 million new RNs to replenish the bench and expand the workforce—and this doesn’t include the premature turnover of nurses who leave the profession because of workplace violence. That turnover will only heighten when nurses are continuously subjected to the continuum of violence in their work environment without proper administrative support in facilitating an ongoing culture of safety.
When you view violence as a holistic concept, it’s immediately clear how seemingly trivial things transmogrify into big ones—it may start with one incident, but can threaten the Care, Welfare, Safety, and Security℠ of your entire organization.

Nurses are critical to sustaining a culture of safety—but they need their leadership to keep them out of harm’s way.

Over a decade ago, the American Association of Critical-Care Nurses (AACN) established a set of six standards for establishing and sustaining healthy work environments—values which have guided nursing administrators in achieving best practices ever since. AACN asserts that nurses can and will thrive in work environments that meet the following standards:
  • Skilled Communication
  • True Collaboration
  • Effective Decision Making
  • Appropriate Staffing
  • Meaningful Recognition
  • Authentic Leadership
These values are supported not only by comprehensive violence prevention training, but are aligned with the expectations of industry regulators, who have stepped up their efforts to hold hospitals accountable if their nurses aren’t afforded a safe work environment. OSHA actively investigates and cites facilities that don’t proactively protect their staff from the risks of workplace violence. These citations typically come along with significant financial penalties for leaving staff in harm’s way.
Because it’s now well established that health care workers face the highest risk of workplace violence, OSHA considers a disregard for meaningful violence prevention in hospitals to be a “willful violation.” A hospital was cited and heavily fined after an investigation discovered about 40 incidents of verbal or physical aggression in just a three-month period—and in the worst of these, a nurse suffered “severe brain injuries” after an assault. Citing management’s failure effectively protect staff from the dangers of disruptive behavior in their hospital, OSHA pointed out that violence prevention training needs to be practical, staff-wide, and a visible part of an ongoing culture of safety to be truly effective.
The scariest part of the story? It’s one of few that actually got logged. OSHA has determined that  far more incidents of workplace violence in hospitals go unreported—even though we know that workplace violence in health care can end in homicide.
The failure to implement and sustain a culture of safety for nurses guarantees needless risk to patients, staff, and hospitals. Not one of these risks is worth taking, but without a culture of safety in place, you’ve effectively taken them all.

Workplace civility training really means holistic violence prevention, and only an evidence-based approach will work.

If you’re serious about shifting your hospital’s paradigm in 2018, you’ll need two things—a proven training program that will effectively and immediately reduce the risks of workplace violence, and a staff-wide commitment to creating and sustaining a culture of safety in your hospital. As the AACN has stated: “AACN calls upon every health care professional, health care organization, and professional association to fulfill their obligation to create healthy work environments where safety becomes the norm and excellence the goal. This vision will only become a reality when these standards and their critical elements have been integrated into everyday practice.”
CPI training bridges the concepts of workplace civility and violence prevention by empowering staff to understand the roots of disruptive behavior and proactively manage a collaborative culture of safety. Our evidence-based curriculum is anchored in the core values of Care, Welfare, Safety, and Security℠—values that support a team approach to reducing the risks of violence and increasing civility among staff, patients, and families served by your hospital.
The training process is a critical time for nurses to find and cultivate common ground. Nurse educator Sara Holland, MSN, RN, has found that in addition to an immediate and lasting reduction in Code Greys and other disruptive behaviors, the implementation of Nonviolent Crisis Intervention® training in her hospital transformed the internal dynamics between staff. Power struggles were more effectively defused or altogether prevented in both staff-to-staff and staff-to-patient interactions, as the collective professional paradigm shifted to a more collegial, collaborative dynamic.
Because nobody knows the challenges facing nurses better than nurses themselves, CPI training empowers key staff members to become on-site Certified Instructors, maintaining the long-term fidelity of your culture of safety. Instructor certification can be earned quickly, includes a full suite of prestige training resources and ongoing access to CPI’s global community of professionals, allowing your nursing department to truly manage and grow their own healthy work environment.
Ultimately, your hospital may determine that like Sara’s, facility-wide, ongoing training is what’s best. This strategy aligns fully with AACN’s Call to Action and supports the meaningful reduction of systemic and dangerous risk to staff, patients, and their families.

We believe nurses deserve a culture of safety, and we’ve helped nursing departments and hospitals achieve that critical paradigm shift for more than 35 years.

We want every nurse to benefit from an established and nurtured culture of safety—it enhances their wellbeing, bolsters their careers, and elevates the quality of care they’re able to give to patients. With decades of experience in developing and implementing effective and lasting workplace violence prevention, we’re excited to help hospitals make this critical culture change for their staff and patients.
“I always tell my students that what they are learning in CPI will not only help them in their careers; but in their personal lives,” said Karena Fisher, nursing officer with HCA. HCA staff members have reported reduced staff turnover, decreased liability, less lost work time, and lowered workers’ comp claims in addition to the key outcomes: reduction in violence, restraint, and seclusion—sometimes by as much as 100%.
They’ve also documented a direct relationship between ongoing training and measurable improvements in HCAHPS scores and patient outcomes. Because CPI training adheres to best practices, including Joint Commission standards, org-wide implementation helps hospitals maintain accreditation and avoid costly penalties.
In fact, so many health care organizations have been able to shift their paradigm and create cultures of safety with CPI training that we’ve dedicated an entire area of our website to documenting their success. The list is growing—will your nursing department be on it?