A Culture of Safety in Health Care? It Starts With Civility.

We’ve talked before about the cultural challenges that nurses face in their work environments. But when key decisionmakers are hesitant to implement real change, it can be nearly impossible for an environment mired in incivility and disruptive behavior to improve and evolve into a culture of safety. The unchecked risks merely fuel more adverse outcomes among staff and patients.

Collaboration is the key to breaking this long-standing dysfunction—and it’s the only way to truly create a culture of safety in health care.

Civility = Safety

Within the scope of nursing, terms like “civility” and “incivility” are polite terms for behaviors that run the gamut from mild impertinence to full-on assaultive behavior—in staff, patients, or patients’ families. 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 Journal of the American Medical Association (JAMA) stated in an April 2021 article that “violence against US health care workers has been on the rise for at least a decade.” The article also says that “attacks against health care workers—already frequent targets for physical and verbal assaults—have evolved during the COVID-19 era.”

In fall 2020, National Nurses United conducted a nationwide survey of more than 150,000 registered nurses. It found that “about 20 percent of nurses report facing increased workplace violence on the job, which they attribute to decreasing staffing levels, changes in the patient population, and visitor restrictions.”

Even before the COVID-19 era, the Online Journal of Issues in Nursing (OJIN), a scholarly journal of the American Nurses Association, shared 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

We can’t let semantics get in the way of sustaining truly safe Environments of Care. “Incivility in the workplace” might sound clinical, but it’s behind behaviors that can lead to incredible harm.

Let’s Talk About What’s Really Happening to Nurses: Workplace Violence

Crisis Prevention Institute defines workplace violence as a continuum of behaviors.

You can immediately see that “violence” spans everything from discourtesy to physical aggression 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 in both staff and patients. When you view violence as a holistic concept, it’s immediately clear how seemingly trivial things can quickly become crises—it may start with one incident, but that one incident can snowball into a threat to the Care, Welfare, Safety, and Security^SM your entire organization.

Decisionmakers Can’t Afford to Wait

In a 2021 survey of nurses, 22 percent indicated they may leave their current position providing direct patient care within the next year. Of these, 60 percent said they were more likely to leave since the pandemic began, driven by a variety of factors, with insufficient staffing, workload, and emotional toll topping the list.

The American Nurses Association (ANA) stated in December 2020 that more registered nurse jobs will be available through 2022 than any other profession in the United States. The U.S. Bureau of Labor Statistics projects that 11 million additional nurses are needed to avoid a further shortage.

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^SM of your entire organization.

Nurses are Critical to Sustaining a Culture of Safety in Health Care—But Leadership Needs to Keep Them Safe

Over a decade ago, the American Association of Critical-Care Nurses (AACN) established a set of six standards for instituting 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

Comprehensive violence prevention training supports these values. It also aligns with 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.

Failing 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, decisionmakers effectively take them all.

Workplace Civility Training? Evidence-Based Holistic Violence Prevention!

If you’re serious about shifting your hospital’s paradigm, 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^SM—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.

CPI believes nurses deserve a culture of safety. We’ve helped nursing departments and hospitals achieve that critical paradigm shift for more than 40 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.