As articles ranging from those in American Nurse Today ("Civility starts with you") to The New York Times ("When the Nurse is a Bully") illustrate, disruptive behavior and incivility in nursing are newsworthy topics and for good reason. Disruptive behavior at work can have serious consequences for both nurses and patients such as stress-related physical and mental health problems and increased medical errors.
The Joint Commission has taken notice of disruptive behavior in healthcare and directs accredited organizations to manage unacceptable behaviors and change their cultures. However, hospitals are at a disadvantage in this area because few studies have examined a broad range of organizational resources that may influence disruptive behavior in healthcare.
In this article, based on National Institute of Occupational Health & Safety (NIOSH) funded research, we describe the research results regarding organizational resources (aggression prevention climate, organizational support, supervisor support, coworker support, and supervisor support for work and family) and care provider disruptive behavior in hospitals. We provide recommendations for nursing leaders to build supportive cultures in their organizations to counter disruptive behavior.
Costs of disruptive behavior
Disruptive and hostile actions toward colleagues, hospital personnel, and patients or visitors can occur a handful of times or daily in the lives of nursing professionals. According to the Joint Commission these behaviors can take the form of:
- hostile, angry or aggressive confrontational voice or body language;
- attacks (verbal or physical) that go beyond the bounds of fair professional conduct;
- inappropriate expressions of anger such as destruction of property or throwing items;
- abusive language or criticism directed in such a way as to ridicule, humiliate, intimidate, undermine, or belittle.
These disruptive behaviors affect their direct targets as well as those who are witnesses to the victimization of others. Health researchers have noted that the impact of disruptive behavior behaviors is also costly for organizations. Disruptive behavior and incivility lead to distress among staff, undermine productivity, contribute to low morale and high staff turnover, and result in ineffective, substandard patient care, poor adherence to practice guidelines, medical errors and adverse outcomes, patient attrition, and malpractice suits.
Our study examined the link between organizational support resources and coworker disruptive behavior in psychiatric settings and found that direct-care providers with greater social support experienced less disruptive behavior and fewer negative health and work consequences due to coworker disruptive behavior.
Findings from our study
Our research used a cross-sectional study design that combined standard and validated organizational support questionnaire measures with validated measures of disruptive behavior, health, family, and work outcomes. We collected survey data from 477 direct care providers working at two psychiatric healthcare settings in the Northwest United States. Survey participation was voluntary, and respondents completed the surveys during their work time. Participants were mostly female (58.8%), with the majority in the 40-49 (25.1%) or 50-59 (35.9%) age ranges. Their average organizational tenure was 7.4 years.
We analyzed our hospital survey data and found that higher levels of an aggression-prevention climate, and coworker support led to less disruptive behavior among direct-care providers. This reflects the significance of organizational support toward countering disruptive behavior and reveals the varied levels within the organization from which this support can be provided.
We also found that higher levels of family supportive supervision led to less disruptive behavior. Family supportive supervisors support the total worker and supervise employees to promote effective work-life management. Care providers with such supervisors may experience a positive effect from the support and recognition and engage in and witness less disruptive behavior.
Our research suggests that high levels of disruptive behavior and incivility are powerful work stressors that take a toll on the health, well-being, and morale of nursing staff care providers and their organization’s leaders.
What nurse leaders can do
Nurse leaders can be nurse supervisors, charge nurses, or front-line nursing staff with informal influence and respect in the work environment. These leaders already have a role in establishing and enforcing the norms and behaviors of the organization and can be key to changing attitudes and actions around disruptive behavior and incivility. Here are some evidence-based actions leaders can take to reduce disruptive behavior.
Provide organizational support
Organizational support reflects employees’ sense that their organization values them, recognizes their contributions, and is concerned with their welfare. Organizational support is linked to quality patient care. Quality of patient care depends on the seamless operation of several different systems and units. Nurses feel appreciated and supported by their organization when these systems run smoothly and when management maintains successful programs and introduces new programs that help these systems improve their function. When care providers believe management is committed to high-quality patient care and that management is responsive to and supportive of their concerns, care providers are more likely to enact positive behaviors, such as therapeutic responses to patients and compliance with new safety procedures.
Foster an aggression prevention climate. Written documents such as codes of conduct, workplace aggression policies, and communication policies are formal expressions of an organization’s aggression prevention climate. In the occupational health psychology research literature, an aggression prevention climate has emerged as the most important factor in preventing workplace aggression.
An aggression prevention climate includes clear organizational policies, practices and responses to support care provider efforts for preventing aggressive incidents. In addition, strong management support exists to assist care providers with their efforts to prevent disruptive behavior among coworkers, or to cope with the negative consequences of being victimized.
Engage in family supportive supervisor behaviors. Leaders can show support for employees through family supportive supervisor behaviors (FSSB), which help employees manage their work and family demands.
These supportive behaviors can be formal or informal and consist of four types: emotional support, instrumental or practical support, role-modeling behaviors, and creative work-family management. Examples of formal support include work-life policies, employee assistance programs (EAPs), and flexible schedule arrangements. Informal workplace supports include listening, expressing concern for the employee’s recovery from work stress, and finding a way for an employee to adjust their work schedule to handle an urgent family situation.
Facilitate coworker support. Support from coworkers can occur in multiple forms, including emotional (for example, listening to a coworker’s difficulties in balancing work and family) and instrumental (for example, offering to help a coworker with a difficult client). The presence of support has been shown to lessen the negative impacts of stress on well-being outcomes.
Work-related support may be more effective than non-work-related support in weakening the effects of workplace stressors on employee well-being. Coworker support has been linked to a number of employee and organizational outcomes, including lower levels of role conflict, role overload, role ambiguity, absenteeism, intention to quit, and turnover, and higher levels of job satisfaction, job involvement, productivity, and organizational commitment.
Organizational research can help identify and prioritize key influences on workplace disruptive behavior and aggression, such as the presence of respectful and professional behavior policies, practices, and procedures. Nursing leaders are needed to enact and sustain those policies and procedures within the organization.
Here are additional evidence-based strategies nurse leaders can use to reduce disruptive behavior:
- Empower and educate their nursing colleagues to advocate for and role model respectful behavior.
- Provide information and education to other care providers on their role as supportive coworkers, and the negative effects of disruptive behavior on patient quality of care and patient and staff safety.
- Collaborate across organizational levels and disciplines to develop professional behavior programs and that focus on providing support resources for staff.
- Set clear expectations for acceptable and unacceptable work behavior.
- Communicate and implement professional behavior policies, and act on reports of disruptive behavior and incivility according to planned procedures.
- Be alert and responsive to uncivil behaviors, including minor incidents of aggression or rudeness, intervene early.
- Encourage your team to be supportive of each other.
- Listen and offer emotional support to staff and colleagues, especially during highly stressful times or after disruptive or aggressive incidents from patients or staff.
- Be accountable to colleagues and other staff when addressing disruptive behavior and incivility from others or oneself.
Employees who experience stronger support from management, supervisors and coworkers will respond with better job attitudes and behavior, which in turn contributes to higher job satisfaction and higher quality of patient care.
Being a role model
Nurse leaders have critical roles as models and voices of their organization. They translate the hospital culture to other employees, role model effective behaviors, and enact organizational policies. They often are the communication link between administration, management and multidisciplinary clinical professionals, as well as between nursing staff. Nurse leaders who consistently communicate and role-model positive standards of behavior help new nursing staff feel safe and valued, while upholding a healthy work environment and quality standards of care that keep both staff and patients safe.
What the research means for nurse leaders
Nurse leaders are crucial to the creation and sustainability of organizational support practices, which may buffer the negative effects of disruptive behavior and incivility on nurses’ work, health, and well-being. Support from nurse leaders can also mitigate the physical and mental strain from one’s job demands and work stress, which may help alleviate some of the mental, physical fatigue, and burnout that can contribute to conflict and mistreatment.
Employees reporting higher levels of workplace aggression may have a greater psychological need for support, especially support that addresses the employee’s ability to contend with the psychological demands of coworker disruptive behavior. In addition to protecting employees from the negative impact of coworker aggression, supportive organizational resources give direct care providers a way to replenish depleted energy related to recovering from stress from disruptive behavior.
Staff civility will likely improve when organizational resources such as an aggression-prevention climate are increased. Knowledge of policies, practices, and procedures in place to protect hospital staff is vital to knowing how to protect oneself from the negative effects of aggressive behavior, and knowing where and how to seek resources from others in the event of an escalating situation.
Building resources along the lines of increasing your organization’s aggression prevention climate, family supportive supervisors, and supportive coworkers is an essential approach toward eliminating disruptive behavior in healthcare settings.
(For more information on this research, see:
Nanette Yragui is occupational health psychologist and principal investigator, Barbra Silverstein is research director, and Whitney Johnson is research analyst for Safety and Health Assessment and Research for Prevention (SHARP) in the Washington State Department of Labor & Industries, Olympia.
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