1. Culture of Civility and Respect: A Healthcare Leader's Role
Provided by the
RWJF Executive Nurse Fellows Program
and funded by the
Robert Wood Johnson Foundation

2. Learning Objectives
Review the effects of incivility and bullying on patient outcomes, human capital, and productivity in health care
Review provided tools to build and sustain cultures of civility and respect in healthcare

3. RWJF ENF Action Learning Team
Rita Adeniran, RN, DrNP, CMAC, NEA-BC FAAN
President/CEO Innovative and Inclusive Global Solutions
Drexel Hill, PA
Beth Bolick, RN, DNP, PPCNP-BC, CPNP-AC
Professor Rush University Medical Center
College of Nursing, Chicago, IL
Ric Cuming, RN, MSN, EdD, NEA-BC, CNOR
VP/Chief Nurse Executive
Einstein Healthcare Network: Philadelphia, PA
Cole Edmonson, RN, DNP, FACHE, NEA-BC 
VP/Chief Nursing Officer Texas Health Resources: Presbyterian Dallas
Bernadette Khan, RN, MSN, NEA-BC
VP Nursing and Patient Care Services
New York Presbyterian Lower Manhattan Hospital
Linda B. Lawson, RN, DNP, NEA-BC
Administrative Director for Health Care Transformation Sierra Providence Health Network - El Paso, TX
Debra White, RN, MSN, MBA, ACNS-BC, NEA-BC
VP/Chief Nursing Officer
Saint Luke’s Health System, Kansas City, MO
* Listed alphabetically, not by weight of contribution
PACERS
Passionate
About
Creating an
Environment of
Respect and
civilitieS
This toolkit was designed by our Robert Wood Johnson Foundation Executive Nurse Fellows project team, the PACERS. We chose this acronym because we are passionate about creating an environment of respect and civilities in healthcare.

4. Incivility & Bullying in the Headlines
Nurse-to-nurse bullying more than just a sore point
Workplace Bullying in Nursing:
A Problem That Can’t Be Ignored
MEDSURG Nursing—September/October 2009—Vol. 18/No. 5
Study Finds Nurses Frequently Being Bullied at Work Nursing News
When the Nurse Is a Bully

5. Defining Incivility & Bullying
Workplace incivility/bullying is any negative behavior that demonstrates a lack of regard for other workers. This can include a vast number of disrespectful behaviors including:  
Harassment
Passive-aggressiveness
Teasing
Gossiping
Purposely withholding business information
Overruling decisions without a rationale
Sabotaging team efforts
Demeaning others
Verbal intimidation
Eye rolling

6. State of the Science
Thirty-five percent of adult Americans (an estimated 54 million workers) report being bullied at work
Perhaps as many, if not more, are bystanders to the negative behavior. The group of bystanders includes not only our coworkers, but our patients, their families, and their visitors
One in six nurses (13%) reported being bullied in the past six months (Sa & Fleming, 2008)
In a study on workplace bullying, most of the respondents reported being bullied by the charge nurse, manager, or director (Johnson & Rea, 2009)
35% percent of adult Americans, an estimated 54 million workers, report being bullied at work.
Perhaps as many, if not more, are bystanders to the negative behavior. The group of bystanders includes not only our coworkers, but our patients, their families, and their visitors; students; our service personnel; and other healthcare professionals.

7. State of the Science (cont.)
Bullying of nurses leads to erosion of professional competence as well as increased sickness, absenteeism, and employee attrition (Hutchinson et al., 2010b; Johnson, 2009; Chipps & McRury, 2012)
Bullying victims may suffer stress-related health problems, such as nausea, headache, insomnia, anxiety, depression, weight changes, and alcohol and drug abuse (Townsend, 2012)
Nurses who survive bullying early in their careers tend to carry their learned behaviors with them. They accept the bully culture as part of the job and eventually may choose to bully other nurses (Townsend, 2012)
In one study on workplace bullying, most of the respondents reported being bullied by the charge nurse, manager, or director. However, incivility and bullying occurs top down, bottom up, and laterally in most of our organizations. It occurs among professions and within professions. A hierarchal relationship is not required.
Health care professionals who survive bullying early in their careers tend to carry their learned behaviors with them. They accept the bully culture as part of the job and eventually may choose to bully other coworkers.

8. State of the Science (cont.)
Almost 21% of nursing turnover can be related to bullying (Johnson & Rea, 2009)
60% of new RNs who quit their first job in nursing within 6 months report that it is because of being bullied
Replacing a nurse can cost up to $88,000 USD (Jones, CB, 2008)
According to a study by the US Bureau of National Affairs, there is a loss of productivity of $5-6 billion/year in the US due to bullying in the workplace
Almost 21% of nursing turnover can be related to bullying and 60% of new nurses who quit their first job in nursing within 6 months report that it is because of being bullied – other professions experience the same rates of turnover.
Replacing a nurse can cost as much as $88,000 US dollars. Replacing anyone in our settings is expensive.
According to a study by the US Bureau of National Affairs, there is a loss of productivity of $5-6 billion/year in the US due to bullying in the workplace.

9. Physical/Psychological Manifestations
Common reactions:
Acute or chronic anxiety
Depression
Sleep interruptions
Fatigue
Lack of mental focus
Post-traumatic stress disorder:
An experience that shatters all you had believed in and valued
Manifestation: Withdrawal, Conversion, Projection

10. Effect on Patient Outcomes
Inattentive health care
Self-doubt
Dismissive treatment of patients
Patients may feel intimidated, embarrassed, or belittled
Bullying leads to erosion of professional competence as well as increased sickness and absenteeism.
Bullying victims may suffer stress-related health problems, such as nausea, headache, insomnia, anxiety, depression, weight changes, and alcohol and drug abuse.
These health problems lead to inattention and inattentive health care professionals are more prone to making errors. Incivility and bullying can erode trust among interprofessional team members and team trust is foundational to reporting those errors such as when a colleague doesn’t follow a quality initiative protocol.
Self-doubt arises when a health care professional reports a patient change and is told that everything is fine, don’t call me again. They probably won’t.
But incivility and bullying don’t just occur among the healthcare professionals. They are also often directed at our patients and their families.
Dismissive treatment of patients is counter to our goals to empower patients to manage their health; and increases risk for malpractice litigation.
Patients may feel intimidated, embarrassed, or belittled and not report key information regarding their health such as not taking their medication, not having the money to fill a prescription, or not testing their blood sugar.
It takes good communication and strong teamwork to manage the complexities of our patient’s health care problems and navigate an ever changing health care system.

11. Costs
Barrier to building and sustaining the human capital needed to maintain a quality health care system
Patients pay the ultimate price

12. Accrediting Standards
The Joint Commission standards addressing hostile behavior in the workplace went into effect in These standards require health care institutions to have in place codes of conduct, mechanisms to encourage staff to report disruptive behavior, and a process for disciplining offenders who exhibit hostile behavior (Joint Commission, Issue 40, July 9, 2008: Behaviors that undermine a culture of safety).
Nursing’s Code of Ethics mandates reporting of unethical behaviors in the workplace (ANA, 2001).
The ANA adopted principles related to nursing practice and the promotion of healthy work environments for all nurses (ANA, 2006).
What happens if despite all of our work and best intentions, the incivility and bullying continues?
Many organizations write “no tolerance policies” to determine repercussions of incivility and bullying. However, caution should be taken in how these are crafted. If the discipline policy escalates too quickly, students and staff may choose not to report for fear of destroying someone’s career.
Patients and families may not report staff for fear of receiving poor care or no care when they need it.
Alternatively, if every incident is handled with a simple conversation over coffee, real change may not occur.
Thus, a balanced approach is needed and policies must be written to start with respectful conversations but lead to severe disciplinary action, including termination of employment, should disruptive behaviors continue.

13. WHY DON’T PEERS ACT? WHY DON’T LEADERS ACT? Lack clarity Lack support
Lack of awareness
Lack of knowledge
Lack tools
Fear
Don't want to become a target
Don't recognize it
Lack of support
Don't want to get involved
Don't know how to intervene

14. Approaches have been Fragmented
Strategies to eliminate incivility/bullying and to create respectful, civil, supportive, and safe environments have largely centered on individuals
However, theory and research establishes incivility/bullying as a complex interplay of influences from interpersonal, community, and environmental sources (See socio-ecological model)
Incivility/bullying is a group phenomenon, reciprocally influenced by the individual, peers, the immediate environment/institution, community, and society
If reducing incivility and bullying is so important to building a workplace of respect; why is it so hard to do? Many health care leaders have published and spoken out about this growing problem.
It may be because strategies to eliminate incivility and bullying and to create respectful, civil, supportive, and safe environments have largely centered on the perpetrators, the individuals.
However, theory and research establishes incivility and bullying as a complex interplay of influences from interpersonal, community, and environmental sources.
Incivility and bullying are a group phenomenon, reciprocally influenced by the individual, peers, the immediate environment/institution, community, and society.
We are at a tipping point, though, with support to learn to address the problem at every level of our organizations.

15. Socio-Ecological Model
Policy
Built / Structural Environment
Communities as Entities
Institutional
Community/Cultural
Relationship
Interpersonal
Individual
Intrapersonal
Socio-Ecological model
Framework for Solutions
Model of human behavior developed from the fields of sociology, psychology, education, and health and focuses on the nature of people’s interactions with others and their environments
Model has gained credibility for its utility in addressing complex human behavioral problems and applicability for designing effective multi-pronged prevention and interventions
Human behaviors, including eliminating acts of incivility and bullying can be improved and sustained when environments and policies support civility
Individuals are motivated, educated, and empowered to be civil

16. Civility & Respect Tool-kit www.stopbullyingtoolkit.org
Free resources to empower healthcare leaders to identify, intervene, and prevent workplace incivility and bullying
Moral Compass
Introduction
How to use the tool-kit
Socio-ecological model
Helpful Links
Grouping of resources into buckets
Truth
Wisdom
Courage
Renewal
Expandable toolkit already downloaded in 23 countries on 5 continents
Is based on the moral compass for respectful, civil conduct/code to live by
This toolkit is specifically intended for use with students during their preparation for careers in health care and for employers to use with new hires during onboarding experiences.
However, it can be also used by anyone or any profession working to build a respectful workplace.

17. Socio-ecological model
Civility Tool-kit
Introduction
How to use the tool-kit
Socio-ecological model
Truth
Civility Quotient Self Assessment
Environmental Assessment
Civility Index Dashboard
Wisdom
Fact Sheet
Slides
Policies
Bibliography
Courage
Mnemonic
Code Words
The Language of Collaboration
Difficult
Conversations
Renewal
Critical Incident
Stress Management
Schwartz Center Rounds
Employee Assistance Program
Courage and Renewal
On the first page – alignment of the tools to the model in the introduction
* The buckets are not in any particular order and are to be used as needed.

18. Truth Tools to assess your self and your environment Truth
Civility Quotient Self Assessment
Environmental Assessment
Civility Index Dashboard
“A culture of disrespect is a barrier to patient safety and quality of care” – Lucian Leape
In this bucket we provide tools to measure where we are personally, in our units or departments, and in our organizations. Knowing where we are and where we want to be, will guide our work.
In every situation of incivility or bullying will be the collaborators, the receivers and givers of the disrespect, and the bystanders.
To build a culture of civility and respect, leaders must address the incivility for both collaborators and bystanders. The impact on bystanders should not be minimized. Remember, bystanders can be other healthcare professionals, students, or the patients, families, and visitors in the setting. Bystanders can experience all the same negative effects as collaborators and need to see that the values of the organization are lived.
Culture is transparent – everyone is part of it and everyone contributes to it.
In the tool-kit bucket labelled “Truth” are assessments, indices, and a dashboard for you to select from and the end of this video to find out where you are in the incivility and bullying spectrum. Do you experience it but not speak up? Do you speak up but feel not listened to? Or, are you the perpetrator? Most of us have been at one time or another. Self-reflection is an important tool for change.

19. Truth
Several assessments including from Dr. Cynthia Clark, a leading expert in the field, have been provided with permission but require attribution for use.

20. Truth: Civility Index Dashboard (CID)
Created as a tool for nurse leaders to assist them in understanding the level of civility in their unit, service line, or organization
Is a macro-micro tool using metrics that are known to be sensitive and predictive of healthy work environments inclusive of civil relationships
The CID as a tool is still in early development with positive reliability and validity already demonstrated
The Civility Index Dashboard (CID) was created and copyrighted by Dr. Cole Edmonson, RN, DNP, FACHE, NEA-BC and Joyce Lee, RN, MSN at Texas Health Presbyterian Hospital Dallas

21. Truth: CID Metrics
Turnover: data is collected using the existing measure from the human resource department
Intent to stay on the unit: data comes from the NDNQI nurse engagement survey
Average tenure: data is collected using the existing measure from human resource department
Variance reports for incivility: data is collected by the risk management department
Call in history
Float Survey: “The Heavenly Seven”
The Heavenly Seven is especially innovative.

22. Truth: Float Survey (The Heavenly Seven)
Data is collected on seven questions by randomly selecting nurses who float in the organization
Survey is completed within 48 hours after the float experience.
The float nurses include the float pool and unit based staff who are required to float. The data is collected using Survey Monkey®
Float survey questions:
I felt welcome on the unit
Someone offered help when I needed it
If floated again, I would enjoy returning to this unit
I had the resources I needed to complete my assignment
I witnessed someone expressing appreciation to another for good work
Staff showed concern for my well-being
I received appreciation for my work
Think of your float staff as the “canaries in the mine”
They live the culture and observe differences among units. If you do not have float staff, think of who your “canaries” are and develop the “Heavenly Seven” for them.

23. Wisdom Tools to obtain knowledge and information Wisdom Fact Sheet
Policies
Slides
Bibliography
“Knowledge if Power” – Sir Francis Bacon

24. Wisdom Incivility and Bullying Fact Sheet Ready reference material
Statistics
Policies
Generic examples/templates
The Joint Commission statement
Slide presentations
Generic/templates
Bibliography
Reference materials
*So do your staff know what it is? We have brief fact sheets, policies, and a slide presentation that can be modified as need to use in your organization.

25. Courage Tools to address behavior Courage Mnemonic Code Words
The Language of Collaboration
Difficult Conversations
“Knowing what’s right doesn’t mean much unless you do what’s right” – Theodore Roosevelt
In this bucket we provide materials to learn to respectfully manage conversations regarding incivility or bullying in or workplaces.

26. Courage: Mnemonic BE AWARE…and Care
noun \ˈker\ : effort made to do something correctly, safely, or without causing damage
Bullying
Exists
Acknowledge
Watch
Act
Reflect
Empower
Emotions and tension can often run high with the increasing acuity of many settings and the numerous stressors, especially for productivity that we all face in health care.
How we handle situations defines who we are. The mnemonic BE AWARE and Care will help you stay focused to the task to reduce incivility and bullying in the workplace. A printable sheet is available in the Courage bucket and should be posted in every healthcare area.
Bullying Exists: Bullying is the most common type of violence in contemporary US society and can exist at any level of an organization. Bullies can be superiors, subordinates, and colleagues.
Bullying is a real problem in healthcare and can become a major issue if it’s ignored or unchecked. Call it what it is. It can lead to a loss of valuable human capital and medical errors.
Acknowledge that bullying may be a problem in your organization. Healthcare leaders should talk about bullying and encourage staff/students to speak up and be heard if it does happen. The more it’s acknowledged, the more you can do about it. Leaders that minimize its impact or deny its existence create a culture of silence that impedes solutions to this problem.
Watch for the signs of the bullying throughout the workplace. Be proactive. Be sure supervisors, managers, and faculty know how to recognize the signs of bullying. Don’t wait for it to be brought to your attention.
Act when you notice signs of bullying by directly intervening, and /or getting help. Bullies lose their power when people stop passively accepting their behavior. Refuse to be a silent bystander. It is everyone’s responsibility to have the courage to play a key role to prevent and stop bullying. Get involved and take a stand against this issue.
Reflect on the incident and your action. Reflect on what was perceived to go wrong and start to reflect on what worked well, and why. Analyzing the incident may help you to:
Ø “reflect-on-action” the past experience,
Ø “reflect-in-action” as an incident happens, and
Ø “reflect-for-action” actions you may wish to take in future experiences.
Empower staff to collectively and safely respond to bullying they see and hear. Create a mechanism for staff to confidentially report bullying issues in the workplace without fear of retaliation.
And of course, CARE because it matters!

27. Courage: Code Word
The organization can choose any code word that’s appropriate in a particular environment to signify that a person is experiencing bullying.
Examples of Code Words that may be considered are:
Code White
Code Grey
Code Black
Code 88
Ouch
Dr. Strong
Dr. Heavy
Strong Alert
In our project team we used the term “ouch”. Our team was passionate on this subject and still periodically we had to use our code word with each other. When we heard it we paused, reflected, and apologized.
Code words can also be code actions such as pulling on one’s earlobe. The idea is to be respectful yet call out the behavior.

28. Courage: The Language of Collaboration
Words have power and how they are used can lead to collaboration or to disrespect. Insulting and judgmental terms are so ingrained in our practice that we often don’t realize how the terms are perceived by others.
Waiting room
Noncompliant
Orders
Frequent flyers
Midlevel provider
Words have power and how they are used can lead to collaboration or to disrespect. Insulting and judgmental terms are so ingrained in our practice that we often don’t realize how the terms are perceived by others.
For example, we use terms such as “order” among healthcare professionals and with our patients and families which reflects a military hierarchy which doesn’t exist. A word such as “prescribe” better suits today’s health care interprofessional team.
Another term is “noncompliant”. It is usually used for patients and families who don’t do what we want them to do. The term again is hierarchal and infers that there is punishment for not doing something. It is judgmental and derogatory.
The term noncompliant does apply, however, if there is a penalty for not doing something such as when one doesn’t pay their taxes on time or doesn’t renew his or her professional license, but it has no place in a respectful collaboration with a patient and family.
A third example is the term “frequent flyer”. It is usually used for patients and families who repeatedly return for care that the health care team considers not justified. The term is derogatory and deleterious to partnership. Instead, when patients and families return more than expected, an assessment is justified to determine patient and family barriers to managing their health.
Language, though is not just verbal, it is physical. When we stand over our patients, families, and colleagues, we present a hierarchal dominance that is a barrier to communication. Crossing ones arms in front, leaning on walls while we speak or listen, playing with ones’ hair, chewing gum, rolling our eyes, and numerous other behaviors are common in our daily settings yet may be perceived as rude, inattentive, or closed off.
Take time after this video to think through which words and behaviors can be perceived as disrespectful in your setting, determine acceptable replacements if needed, and commit to change.

29. Courage: Difficult Conversations
Why are they called “difficult conversations” and who are they for?
Emotionally charged
There may be a power differential between those having them
There is often a fear of retribution for expressing a person’s feelings and perceptions
It is a skill to be learned.
These conversations are also referred to as difficult and crucial conversations because they are emotionally charged, there may be a power differential between those having them, and there is often a fear of retribution for expressing a person’s feelings and perceptions.
Difficult conversations are just that, difficult. Difficult conversations take courage to participate in from both the giver and the receiver’s perspective. However, difficult conversations must occur - they are crucial - so that true communication and collaboration can be reached. They occur at all levels of an organization and between every profession.
Of the many terms that can be used for these conversations, we suggest that we use the term respectful conversations for difficult situations to keep our goal of civility at the forefront.
Numerous authors have recommended approaches to these difficult, crucial, and respectful conversations; each approach manages the conversation through a series of steps. Regardless of the steps, these conversations are a skill to be learned just as we learn to take a blood pressure, complete a history and physical examination, or write a business plan.
To keep the steps handy, we have provided a pocket card that can be downloaded and laminated for durability.
Additional respectful conversation training tools are coming this summer and include a facilitator’s guide and 3 videos.

30. Renewal Tools and resources to support healing Renewal
Critical Incident Stress Management
Schwartz Center Rounds
Employee Assistance Program
Courage and Renewal
“What lies behind us and what lies before us are tiny matters compared to what lies within us.” – Ralph Waldo Emerson
Now that we have talked about the first three buckets in our tool kit, truth, wisdom and courage it’s time to learn about the final one – renewal. Helping victims of bullying events to recover, renew, and heal. We are going to talk about 4 different approaches:
Critical incident stress management
Schwartz Center Rounds
Employee Assistance Programs
And Courage and Renewal – based on the work of Parker Palmer

31. Renewal: Critical Incident Stress Management (CISM)
Critical incidents are determined by how they undermine a person's sense of safety, security, and competency in the world.
Key to any organization’s ability to prevent and reduce stress in its workforce is to provide staff with programs and resources to address stress and to identify and remove the inciting stressor, in this case incivility and bullying, from occurring.
Critical Incident Stress Management, or CISM, is an intervention protocol developed specifically for dealing with traumatic events. It is a formal, highly structured and professionally recognized process for helping those involved in a critical incident to share their experiences, vent emotions, learn about stress reactions and symptoms and given referral for further help if required. It is not psychotherapy. It is a confidential, voluntary and educative process, sometimes called 'psychological first aid'.
First developed for use with military combat veterans and then civilian first responders, it has now been adapted and used virtually everywhere there is a need to address traumatic impact in peoples lives. Certification in critical incident stress management is available to help prepare competent professionals, skilled in appropriate intervention.

32. Renewal: Schwartz Center Rounds
Caregivers have an opportunity to share their experiences, thoughts, and feelings on thought-provoking topics drawn from actual patient experiences
The interprofessional rounds are based on the understanding that healthcare professionals are better able to connect with colleagues and patients when they have broader understanding of their own feelings and emotional responses
A Schwartz Center rounds participant said it best, "Schwartz Center Rounds sessions are a place where people who don’t usually talk about the heart of the work are willing to share their vulnerability, to question themselves. The program provides an opportunity for dialogue that doesn't happen anywhere else in the hospital.”
The Schwartz Center Rounds program, now taking place in 39 states and more than 320 healthcare facilities offers HC providers a regularly scheduled time during their fast paced work lives to openly and honestly discuss social and emotional issues that arise in caring for patients. A hallmark of the program is interprofessional dialogue. Panelists from diverse professions participate in the sessions, including physicians, nurses, social workers, psychologists, allied health professionals and chaplains. After listening to a panel’s brief presentation on an identified case or topic, caregivers in the audience are invited to share their own perspectives on the case and broader related issues.
Caregivers who participated in multiple Schwartz Center Rounds sessions reported:
Increased insight into social and emotional aspects of patient care; increased feelings of compassion toward patients; and increased readiness to respond to patients’ and families’ needs. In addition they reported,
Improved teamwork, interdisciplinary communication, and appreciation for the roles and contributions of colleagues from different disciplines. Finally they reported,
Decreased feelings of stress and isolation, and more openness to giving and receiving support.

33. Renewal: Employee Assistance Program
Employee benefit programs offered by many employers intended to help employees deal with personal problems that might adversely impact their work performance, health, and well-being
Employee assistance programs generally offer a wide range of help – from social services and community resources to professional counseling and psychotherapy.
An EAP's services are usually free to the employee and their household members, having been pre-paid by the employer. In most cases, an employer contracts with a third-party company to manage its EAP. Some of these companies rely upon other vendors or contracted employees for specialized services to supplement their own services, such as: financial advisors, attorneys, travel agents, elder/child care specialists, and the like. Confidentiality is maintained in accordance with privacy laws and ethical standards.
EAP services are excellent resources to assist either victims of bullying or perpetrators.

34. Renewal: Courage and Renewal
Courage and Renewal is based on the work of Parker Palmer and his book Let Your Life Speak.
The Courage and Renewal Centers located through out the U.S. bring this work to life through facilitated groups, safe circles of trust, and guided imagery and poetry through a group of trained facilitators. The purpose of the work is to help those in caring and service professions to be grounded in who they are, inside and out, or authenticity. To create a powerful connection between the inner and outer person that allows them to live more fully.
In 1997, Parker J. Palmer with Rick and Marcy Jackson founded what would become the Center for Courage & Renewal. First known as the Center for Teacher Formation, it began as a program within the Fetzer Institute. Courage to Teach became the premier program helping teachers connect soul with role, rekindling their passion for educating the whole student.
As the Center’s Circle of Trust approach grew more popular within the teaching profession as well as other social sectors, the Center for Courage and Renewal was established as an independent nonprofit in Programs are now available for leaders in healthcare, ministry, business and community settings, as well as to everyone wishing to become more authentic and self-aware in their life and work.
The Circle of Trust® approach is distinguished by principles and practices intended to create a process of shared exploration—in retreats, programs and other settings—where people can find safe space to nurture personal and professional integrity and the courage to act on it. In the hands of a knowledgeable and skilled facilitator, this approach has the power to transform individuals, families, workplaces and communities.

35. Healthcare Leaders Responsibility
HEALTH CARE LEADERS have a RESPONSIBILITY to employees, students, and the public to provide work and school ENVIRONMENTS that are FREE FROM ABUSE AND HARASSMENT. When WORKPLACE BULLYING has been identified as a PROBLEM, senior leaders must take SWIFT, APPROPRIATE ACTION to ensure the ABUSE STOPS, the PERPETRATOR is held ACCOUNTABLE, and steps are taken to ensure bullying does not occur again. POLICIES and PROCEDURES must be implemented and ENFORCED to ensure staff and students FEEL SAFE to REPORT INCIDENTS of incivility/bullying.
It is healthcare leaders responsibility to provide an environment free of abuse and harassment. When incivility does occur, we need to take quick action and hold those accountable so that the abuse stops. Part of this work includes policies and procedures but also ensuring that they are enforced. As leaders we need to be sure nurses feel safe to report these incidents…

36. Call to Action www.stopbullyingtoolkit.org www.stopbullingtoolkit.com
Incivility and bullying inhibits building and sustaining a culture of respect. It is detrimental to optimal patient outcomes.
Healthcare leaders in both medical center and professional schools must identify, intervene, and prevent workplace bullying
We all must learn the skill to address incivility in the workplace; it needs to be built into every curriculum and every orientation
So this is a call to action.
Incivility is a patient safety issue that can and must be addressed by courageous leaders. In order to address incivility we have to be on the look out for it, be able to recognize it when we see it, and be comfortable responding to it. We are responsible for creating environments of respect and civility – as leaders we influence the environment by what we permit and what we don’t.
Go to the toolkit and commit to “do one thing” this week.
Listen to the recorded webinar for a review.
Read the introduction to find out how the tools are designed to work.
Then go to each bucket and download the tools.

37. October is Anti-bullying Month
The Civility Pledge:
I pledge to behave with civility, treating myself and others with respect and consideration.
I pledge to compassion & curiosity.
I pledge to be gracious, honest, authentic, and wholly present – right here, right now.
I pledge to invite others to take the Pledge and to engage intentional and civil conversations.
Show of hands – how many of you knew that October is anti-bullying month? The PACERS hope that you will join us and take the Civility Pledge, perhaps bring it back to your workplaces and have others take it with you. We also hope that you will courageously implement one or more of the various anti-bullying techniques that we’ve spoken about today. It’s not too early to start planning for October.

38. References
American Nurses Association. (2009). Lateral violence and Bullying in nursing.
American Nurses Association. (2006). Resolutions: Workplace abuse and harassment of nurses. Retrieved from
Chipps, E. M., & McRury, M. (2012). The development of an educational intervention to address workplace bullying: A pilot study. Journal for Nurses in Staff Development, 28(3),
Hutchinson, M., Wilkes, L., Jackson, D., & Vickers, M. H. (2010). Integrating individual, work group and organizational factors: Testing a multidimensional model of bullying in the nursing workplace. Journal of Nursing Management, 18(2),
Jones, C.B. (2008). Revisiting nurse turnover costs: Adjusting for inflation. Journal of Nursing Administration, 38(1), 11-18

39. References
Johnson, S.L. (2009) International perspectives on workplace bullying among nurses: a review. International Nursing Review, 56, 34–40
Johnson, S. L., & Rea, R. E. (2009). Workplace bullying: Concerns for nurse leaders. Journal of Nursing Administration, 39(2),
Sa, L., & Fleming, M. (2008). Bullying, burnout, and mental health amongst portuguese nurses. Issues in Mental Health Nursing, 29(4),
The Joint Commission. (2008). Sentinel event alert. Behaviors that undermine a culture of safety. Issue 40.
Townsend, T. (2012). Break the bullying cycle. American Nurse Today, 7(1).