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topic of conflict or bullying, while others were written in response to a previous post or news story.
We further reviewed the selected blogs and numbered each post consecutively. We then read each post individually and independently to analyze them for themes related to conflict, cynicism, or chaos.
Once we had reviewed all posts and grouped them in themes, we met to discuss our results, collapsing and categorizing them into larger content areas of meta-themes (categories), which became 16 chapters of the book. When there was disagreement and we could not reach consensus, we consulted a third nurse expert to provide their interpretation. This expert and a fourth nurse/administrator/reviewer then reviewed the final categories to confirm that they captured “real-life” sources of conflict in the workplace.
We then constructed narrative scenarios based on each theme (with the exception of four scenarios that were submitted to us specifically for inclusion in the book). We compared each scenario to original blog posts emerging from the specific theme for veracity. Further, we compared the scenarios with 50 written narratives shared during workshops, lectures, and email correspondence as a further confirmation of validity. Although the process we used to generate scenarios was not rigorous or categorized as research, we conducted it using a thoughtful and scholarly approach that would lead to valid conclusions. The commentary provided by the experts was lightly edited without altering the actual content.
Each chapter begins with an overview of particular areas where nurse toxicity often arises. Following that is a section titled “Clearing Toxicity: Scenarios, Insights, and Reflections.” Here you will find scenarios based on real-life accounts, with insight and advice from nurse leaders—a group of 31 experts in nursing management that were asked to respond to the narratives from the perspective of preventing, addressing, or minimizing the consequences of conflict. These experts were identified through personal contacts, literature review, and recommendations from colleagues. Experts were asked to avoid citing references and rely on their own experiences and intuitive skills to provide practical advice about the situation. Following the “Nurse Leader Insight” section are “Reflections” with prompts to help readers explore the issues presented.
At the end of each chapter is a section called “Fostering Cultural Change” that can help guide you as you explore with your staff methods to decrease toxicity and promote a healthier and more satisfying work environment. Toxic Nursing, 2nd Edition helps nurses—from bedside nurses to charge nurses to nurse managers—navigate the nuances and gray areas of toxic behavior.
1 | incivility
In recent years, many people have begun discussing the perception that interpersonal discourse has become increasingly uncivil—including in the workplace. Marlantes (2011) traces the roots of this discussion back to 1997, when the founder of the Public Conversations Project facilitated a retreat to discuss acrimony in the workplace. Now, so-called “civility coaches” offer their services to improve the emotional climate at workplaces, while career counselors help organizations create a culture of mutual respect.
While the word bullying is often used interchangeably with the word incivility, we usually think of individuals who are aggressive as opposed to environments that are intolerant. In any workplace, being uncivil involves a range of behaviors. The American Nurses Association (2015) suggests that incivility exists on a continuum, in the form “of rude and discourteous actions, of gossiping and spreading rumors, and of refusing to assist a coworker” (p. 2). Depending on the intensity and frequency, these can add up to a toxic work environment.
Lower (2012) says that “almost everyone who works in healthcare has a story to tell about disrespectful behavior” (p. 21). Citing several studies that support the idea of civility and collaboration with positive patient outcomes and vice versa, she asserts that “civility can be the foundation for patient safety, a healthy work environment, healthy staff, and increased productivity. Civility affects the quality and quantity of our hard work. Incivility, in contrast, is a short step away from aggressive behavior, which can lead to lateral or horizontal violence.”
I’ve been told about many workplaces with civility problems—and the toxic fallout that results. Sometimes, it is just a matter of one nurse “yelling” at another; other times, harsh and demeaning comments were made in front of coworkers or patients. Communications that turned threatening or berating were also reported, along with physicians who verbally aggressed against nurses. These behaviors have a negative effect not only on those directly involved but also on others who witness them.
Another issue that fed into a negative environment in the workplace was organizational cynicism. Nurses who incessantly found fault with the management or organization and constantly suggested changes created a climate of dissatisfaction in the workplace. (You can read more about organizational cynicism in Chapter 16.) Dr. Judith Orloff (2005) describes people who leave you feeling “exhausted down to your very last molecule” as “energy vampires,” a term that fits the feeling nurses described when confronted by coworkers who were bitter and organizationally cynical.
In a study of 900 nurses, Cornwall (2018) found that 39% of nurses had experienced “bullying” at work, with 30% claiming the most common source was verbal harassment from other nurses and 22% claiming administrators were aggressors. These figures represent a slight decline from a report in 2016, where 45% of nurses felt bullied by other nurses.
Yildirim (2009) found that incivility from nurse managers created an environment that not only feels unsafe but affects a nurse’s life both on and off the job. In a sample of 286 seasoned female nurses, 40% of those who were treated aggressively said that administrators were the bullies. Job motivation, energy level, and commitment to the job were significantly and negatively affected.
Russell (2012) offers these tips for increasing civility at the workplace:
• Identify positive role models who display the behaviors you seek. Administrators must lead the way in training themselves to act with civility.
• Take prompt action when you see incivility. Zero-tolerance policies are fine, but they’re meaningless if they’re not enforced.
• Encourage all employees to think about their level of civility. You might use a survey, a scenario, or a situation to prompt discussion on minimally acceptable workplace behaviors.
• Educate employees on anger and stress management techniques as well as communication. While some degree of conflict will always be present—perhaps even healthy—you must understand when those emotional emails cross the line from encouragement to criticism.
• Weekly civility tips can reinforce desired behaviors.
• Pay attention to dress codes. There’s some support for the idea that a sloppy appearance can result in diminishing professionalism.
• Be on time. If you’re late, apologize.
• Ask for and be open to feedback on your performance. Encourage others to give you a civility report card every now and then.
I also encourage you to have a proactive plan in place for prevention of on-the-job relational aggression (RA). Knowing that when you see tension mounting or witness the potential for the deterioration of relationships, you will walk away, talk it out, or tell someone who can remediate (Dellasega, 2019) will prepare you to respond. Often, the sting of RA is compounded by its unexpected nature. One minute you are working collaboratively with your teammates and the next you are singled out for not answering call bells.
As a nurse manager, discussing healthy ways to discuss and dismiss frustration is a valuable intervention. Having an open dialogue on how to confront coworkers constructively before an actual crisis occurs can establish guidelines everyone can follow and prevent discord.
Commentator Beth Boynton notes the following:
In going from a toxic to healthy culture, key interventions include setting new