Impact of Behaviors that Undermine a Culture of Safety on Adverse Patient Events:
An Evidence-Based Project
By
Susan Farley, Rhonda Garretson, Jennifer Singsank-Leffler
Submitted in Partial Fulfillment
of the Requirements for the Degree
Master of Science in Nursing
Nebraska Methodist College
Department of Nursing
Omaha, Nebraska
Under the Supervision of
Dr. Christopher J. Smallwood, PhD, RN
July, 2015
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Table of Contents
Title Page .........................................................................................................................................1
Table of Contents ............................................................................................................................2
Abstract ............................................................................................................................................5
Introduction .....................................................................................................................................6
Problem .......................................................................................................................................6
Purpose ........................................................................................................................................7
Background .................................................................................................................................8
Theory/Model .............................................................................................................................9
Significance ..............................................................................................................................10
Setting.......................................................................................................................................11
Stakeholders .............................................................................................................................12
Cost Benefits ............................................................................................................................12
Desired Outcome ......................................................................................................................13
PICO(T) Question ....................................................................................................................13
Search Plan Method .......................................................................................................................14
Search Plan Discussion ............................................................................................................14
Statement of Special Sources/Journals .....................................................................................14
PICO(T) Terms .........................................................................................................................15
Database Search Strategy .........................................................................................................15
Inclusion/Exclusion Criteria .....................................................................................................16
Analyzing the Literature ................................................................................................................17
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Literature Introduction ............................................................................................................17
Levels of Hierarchy of Evidence .............................................................................................17
Critical Appraisals ...................................................................................................................18
Article one: Laschinger (2014) ...........................................................................................18
Article two: Flynn, Liang, Dickson, Xie, and Suh (2012) ................................................19
Article three: Chipps, Stelmaschuk, Albert, Bernhard, and Holloman (2013)...................20
Article four: Walrath, Dang, and Nyberg (2010) ...............................................................22
Article five: Walrath, Dang, and Nyberg (2013) ..............................................................24
Article six: Roche, Diers, Duffield, & Catling-Paull (2010) .............................................26
Article seven: Wilson and Phelps (2013) ..........................................................................27
Synthesis Discussion of Evidence .................................................................................................29
New Understandings Generated by Evidence .........................................................................30
Limitations ..............................................................................................................................33
Implications/Impact of Evidence ............................................................................................34
Future Recommendations about Nursing Research ................................................................36
Future Recommendations about Nursing Education ...............................................................37
Future Recommendations about Nursing Administration .......................................................38
Future Recommendations about Nursing Practice ..................................................................39
Conclusion .....................................................................................................................................40
Reference List ................................................................................................................................42
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Appendix A ....................................................................................................................................47
Search Flow Diagram
Appendix B ....................................................................................................................................49
Critical Appraisals
Appendix C ....................................................................................................................................80
Matrix
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Abstract
The purpose of this evidence-based project was to understand the impact of clinician behaviors
on patient safety events. The PICO(T) question represented is “Among hospitalized patients in
acute care settings, how do behaviors that undermine a culture of safety affect the occurrence of
adverse patient safety events?” Through a literature search using the Cumulative Index to
Nursing and Allied Health Literature and PubMed databases, a hand search, and identified
PICO(T) question terms, seven relevant articles were found. The literature analysis demonstrates
increasing evidence supporting an association between behaviors that undermine a culture of
safety and adverse patient safety events, presenting significant implications for the well-being of
patients, staff, and healthcare organizations. More research is needed regarding the complexity of
care, and all aspects of the clinician behavior construct. Recommendations for future nursing
research include study of the practice environment and causation of behaviors that undermine a
culture of safety. Future recommendations for nursing education include behavior recognition,
conflict resolution, assertiveness training, and action steps when undermining behaviors occur.
Recommendations for future nursing administration include establishing a positive practice
environment, role modeling desired behavior, and empowering employees in establishing and
maintaining an optimal safety culture. Future recommendations for nursing practice include
advocating for staff education, behavior standards and accountability, as well as establishing a
personal commitment of responsibility to foster a healthy practice environment. Understanding
and addressing behaviors undermining a culture of safety must be a priority in order
for healthcare organizations to achieve the high-reliability outcomes seen in other industries.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
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Impact of Behaviors that Undermine a Culture of Safety on Adverse Patient Events:
An Evidence-Based Project
There are varying terms characterizing behaviors that undermine a culture of safety in the
workplace but research on what can be learned from those behaviors, including their
consequences, needs continual exploring. If behaviors that undermine a culture of safety take
place between healthcare team members, a breakdown in workflow can take place along with
undesired patient outcomes. With the constant change dynamic in healthcare and the demand for
increasing transparency among its organizations, it is vital to research how these undermining
behaviors impact patient safety and then use that knowledge to develop strategies to effectively
address them.
Problem
Behaviors that undermine a culture of safety are broad in scope, characterized by such
terms as bullying, incivility, hostility, disruptive behaviors, and lateral/horizontal violence. A
2010 study demonstrated that 24 percent of registered nurses (RNs) reported experiencing a
hostile workplace and 56 percent reported experiencing verbal abuse during the last year in
which they worked (Buerhaus et al., 2012). These findings are relevant since a hostile workplace
can interfere with a positive patient safety culture. Laschinger (2014) shared study outcomes
linking negative patient safety cultures to increased work-related injuries, high medication error
rates, and reluctance to report errors, and Squires’ findings that supportive professional practice
environments are key to maintaining a patient safety climate.
Laschinger (2014) discusses a definition of bullying as a repeated and prolonged
exposure to psychological mistreatment directed as a specific target, and a definition of incivility
as referring to low-intensity rude or disrespectful behaviors. The American Medical Association
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
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describes disruptive behavior as verbal or physical personal conduct that potentially or actually
negatively affects patient care, including but not limited to conduct which prohibits the ability to
work with healthcare team members (Walrath, Dang, & Nyberg, 2010). The World Health
Organization‘s definition of violence includes actual or threatened intentional use of power
against others with a high likelihood of harm (Roche, Diers, Duffield, & Catling-Paull, 2010).
Stanley, Martin, Nemeth, Michel, and Welton describe lateral or horizontal violence as any
unwanted abuse or hostility within the workplace; Jackson, Firtko, and Edenborough
characterize lateral/horizontal violence as a series of undermining incidents over time as opposed
to an isolated conflict incident (Becher & Visovsky, 2012).
Failure to address destructive clinician behaviors causes toxicity in the care environment
to grow. Despite what is espoused as company core values, employees take their cues from those
around them and adjust their behavior to fit in to the work environment; nothing is more
destructive than the failure of leaders to manage these behaviors in their organizations (Porter
O’Grady & Malloch, 2011). System stressors fueling the propensity for disruptive behavior
include pressures to maintain patient throughput, a complex work environment, clinicians’
personality characteristics, role differences, and team member turnover (Walrath, Dang, &
Nyberg, 2013). Regardless of etiology, these behaviors put patient safety at risk by negatively
impacting the caregivers that patients entrust with their care.
Purpose
While there has been significant examination of a negative workplace on nurse outcomes,
it is important to understand the impact of clinician behaviors that undermine a culture of safety
on patient outcomes. The aim of this study is to complete a review of the literature to more fully
determine the effects of clinician behaviors that undermine a culture of safety on the occurrence
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
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of adverse patient safety events. This exploration will assist health organizations in setting
priorities for enhancing interventions to improve patient safety.
Background
The climate of the care environment and its’ impact on patient safety has been an
increasing area of focus for influential organizations in healthcare. Recognizing the negative
impact that disruptive behaviors have on patient safety, the Joint Commission (TJC) published a
Sentinel Event Alert in 2008 addressing this issue. TJC (2008) states “Intimidating disruptive
behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable
adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and
managers to seek new positions in more professional environments” (p. 1). TJC regulatory
standards were subsequently amended to require organizations to have a code of conduct which
defines destructive behaviors along with a process in place for managing them (Walrath, Dang,
& Nyberg, 2010).
Interestingly, disruptive behavior is a term commonly used in the literature and
previously adopted by the Joint Commission (TJC) in their accreditation materials. However,
because some health practitioners had a negative view of this terminology and it was considered
ambiguous for some audiences, TJC replaced this term with behaviors that undermine a culture
of safety, effective July 01, 2012 (TJC, 2012). Because this change confounds scholarly review,
behaviors that undermine a culture of safety will encompass multiple terms for purposes of this
study, including disruptive behavior, bullying, incivility, and lateral/horizontal violence.
Previous studies have addressed behaviors resulting in abusive work environments. In a
1997 qualitative study, Farrell found that lateral violence was more stressful for nurses than
physical assault from patients (Roche, Diers, Duffield, & Catling-Paull., 2010). In a 2005 study,
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Rowe and Sherlock concluded that verbal bullying results in job stress, job dissatisfaction,
missed work, and possibly decreased quality of care (Roche et al., 2010). Prior to embarking on
their survey study conducted January 2004 through March 2007, Rosenstein and O’Daniel
(2008) could find no documented studies directly linking disruptive behavior to negative clinical
outcomes. Findings of their study revealed that 67 percent of the respondents agreed that
disruptive behaviors were linked to adverse events – the result for medical errors was 71 percent
and the result for patient mortality was 27 percent (Rosenstein & O’Daniel, 2008). The World
Health Organization (WHO) recently identified workplace bullying as a serious public health
threat (Laschinger, 2014).
Theory/Model Description
Understanding the different influences from theories of social learning and oppression is
essential in understanding why behaviors that undermine a culture of safety occur in the
workplace. In trying to explain the influences of theories on these negative behaviors, the Social
Learning Theory and the Nursing Oppression Theory will be discussed. While the Social
Learning Theory involves mimicking of negative behaviors, the Nursing Oppression Theory
involves displaced anger.
First, the Social Learning Theory can explain why coworkers imitate negative behaviors
seen in the workplace. Walrafen, Brewer, and Mulvenon (2012) state that “Based on Bandura's
theory, the workplace (world) and the employees (individuals) on some level cause each other's
behavior (reciprocal determinism)” (p. 3). Some employees will see negative behavior
happening in the workplace and choose to go along with it to try to fit in and be accepted by
others.
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Secondly, the Nursing Oppression Theory can help explain why there is hostility in
healthcare among nurses and why behaviors that undermine a culture of safety exist. “Freire
theorized that oppressed people internalize their situation by adopting the dominant group’s
beliefs and values while minimizing their own” (Purpora & Blegen, 2012, para. 10). This theory
helps explain why nurses feel less important and powerless in unhealthy work environments and
can displace their hostility and anger towards others.
Significance
Focus on safety and quality is at the forefront in healthcare, now more than ever before.
Once monitored internally only, health outcomes are increasingly in the public view and are now
tied to service reimbursement. Hospitals in particular are under increasing pressure to improve
care while reducing costs (Hines & Yu, 2009). Health Grades estimates that medical errors cause
approximately 195,000 deaths annually in the United States (Hines & Yu, 2009). If the airline
industry harmed as many people as healthcare, an angry outcry for reform from American
citizens would take place throughout the country (Kerfoot, 2009). To frame it another way, “a
checked bag on an airline flight is exponentially safer than a patient in an American hospital”
(Nance, 2008, p. iii).
There is a significant financial cost to patient harm. James found that medical errors in
the United States are the third leading cost of death in hospitals, costing an estimated $17-$30
billion per year (Sahay, Hutchinson, & East, 2015). If a transformed healthcare system means
high quality, cost efficient care for American citizens into the future, healthcare performance
must move toward the transparency and high reliability of the airline industry; in order to do that,
the barriers which are currently in the way of that objective must be understood.
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Much effort has been focused on preventing hospital acquired conditions since the
Centers for Medicare and Medicaid Services (CMS) changed their regulations in 2008
eliminating additional payment for these conditions, with additional provisions related to the
Affordable Care Act only escalating the pay for performance climate. A 2010 study of registered
nurses (RNs) and their perceptions of the healthcare environment found that 79 percent of
respondents reported an increase in the number of performance improvement initiatives targeting
hospital acquired conditions since the new CMS regulations were enacted (Buerhaus et al.,
2012). However, part of the safety equation less explored is the environment of care in which
caregivers practice and whether it is one that inhibits or promotes patient safety. The issue of
behaviors that undermine a culture of safety and the impact on adverse patient safety events are
in alignment with the Quality and Safety Education in Nursing (QSEN) competency of Safety
and must be explored to better understand their influence on healthcare’s most critical
component - patient outcomes.
Setting
Behaviors that undermine a culture of safety have the potential to take place in any
setting where members of a healthcare team are working in collaboration to care for patients.
Behaviors interfering with a culture of safety persist when there is tolerance and indifference,
unwillingness to address it, and lack of awareness of the prevalence and impact on all aspects of
the healthcare team including patients (Walrath, Dang, & Nyberg, 2013). These places include
acute care settings, outpatient settings, and long term care facilities. For the purpose of this
study, the focus will be on the acute care setting. According to the Department of Health and
Human Services, 26% of hospitalized Medicare beneficiaries experienced an adverse event
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during their hospital stay; forty-four percent of these were found to be preventable on physician
review (Levinson, 2010).
Stakeholders
Patients are the main stakeholders in this discussion, as they are seeking care and it is
their wellbeing that is affected by the outcome of negative behaviors. The second main
stakeholders are the providers of care; nurses, physicians, and ancillary staff. Adverse patient
outcomes have the potential to impact the professional and psychological well-being of the care
giver through potential employment or licensure ramifications, feelings of remorse, and potential
litigation. Hostile work environments, which include behaviors that undermine a culture of
safety, may cause decreased employee retention as nurse’s satisfaction decreases and they seek
employment elsewhere. Newly graduated nurses may be increasingly vulnerable and more
predisposed to making medication errors as they lack familiarity with the work environment
(Sahay, Hutchinson, & East, 2015).
Other stakeholders include the families of the patients experiencing adverse patient safety
events, the healthcare institution, and the agencies reimbursing the healthcare institution for the
services provided. There have been many changes in reimbursement since 2008 when the
Centers for Medicare and Medicaid started changing reimbursements for preventable adverse
events. The changes mean that “Hospitals would be prohibited from billing Medicare for
“serious, preventable adverse events” (Sohn, 2011, para. 5).
Cost Benefits
Adverse patient outcomes are costly for institutions. The amount paid out by Medicare
only covers one-third of the cost incurred from treating these patients, leaving a large deficit that
must be covered by the healthcare institution (Zhan, Friedman, Mosso, & Provost, 2006). This
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lapse in funding has brought patient safety to the forefront and made it a renewed priority for
administration as well as staff. The Centers for Medicare & Medicaid Services (2008) continue
to monitor “never events” (errors that take place in healthcare that are costly and serious) and
make determinations on what services and conditions they will and/or will not reimburse for.
Desired Outcome
The desired outcome of this literary review is to better understand the impact of
behaviors that undermine a culture of safety among clinicians and the occurrence of adverse
patient safety events. An adverse patient safety event is defined by the American Academy of
Orthopaedic Surgeons as, “one that causes injury to a patient as the result of a medical
intervention rather than the underlying medical condition. It represents unintentional harm to the
patient” (Attarian, 2008, para. 3). In keeping with TJC and changes in terminology behaviors
that undermine a culture of safety is an overarching term that includes lateral violence, disruptive
behaviors, bullying, and incivility. Adverse patient outcomes would include hospital acquired
infections, medication errors, patient falls, and wrong site surgeries.
The results of this review will provide an analysis of how behaviors that undermine a
culture of safety adversely affect patient outcomes. This study will allow healthcare
organizations enhanced insight into the need for policies that support a healthy workplace and
provide assistance with identification of strategies to achieve respectful, productive work
environments. Such efforts will facilitate collaborative healthcare teams promoting the best
possible outcomes for every patient, every time.
PICO(T) Question
The cost of medical errors in the United States in 2008 was 19.5 billion dollars and costs
are continuing to rise. There was an estimated 200,000 people that died from preventable
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medical errors (Andel, Davidow, Hollander, & Moreno, 2012). The key question to ask now is:
Among hospitalized patients in acute care settings, how do behaviors that undermine a culture of
safety compared to the absence of those behaviors, affect the occurrence of adverse patient safety
events? This question follows the PICO(T) format outlined in Melnyk and Fineout-Overholt
(2011) that will lead to the most relevant and evidenced based research.
Search Plan Method
Search Plan Discussion
Healthcare is rapidly changing and outcomes from the most current research are required
to promote evidence-based care. “Frequently updated bibliographic and/or full text databases that
hold the latest studies reported in journals are the best, most current choices for finding relevant
evidence to answer compelling clinical questions” (Melnyk & Fineout-Overholt, 2011, p. 42).
The Cumulative Index of Nursing & Allied Health Literature (CINAHL Plus) and PubMed were
the chosen databases to use in this search as both are expansive in scope. A computer search was
conducted based on PICO(T) terms using Boolean operator methodology. This search presented
a particular challenge in that both the intervention and the outcome focuses of the study are
captured in a broad array of phrases throughout the literature, requiring a particularly extensive
search of various terms and combinations. However, Raines (2013) informs us that the goal of a
literature search is to identify evidence to support practice regardless of the obstacles that
obtaining such evidence presents.
In addition to the databases, a computer search of Google Scholar was also conducted,
along with manual searches to try and maximize results. The importance of the search method
should not be underestimated. Knowledge of how to effectively access the literature helps to
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close the divide between evidence from research, and practice based on tradition in the clinical
setting (Raines, 2013).
PICO(T) Terms
Table 1. PICO(T) Terms
PICO(T)
Terms
P (population)
Hospitalized patients
I (intervention)
Lateral/horizontal violence, workplace violence, incivility,
hostility, disruptive behavior, clinician disruptive behavior
Disruptive behavior prevention
C (comparison)
O (outcome)
T (time)
Patient safety, patient outcomes, medication errors, patient falls,
wrong site surgery
No terms used
Database Search Strategy
The search was begun in CINAHL Plus with the population term “hospitalized patients”;
when combined with each intervention term using the Boolean operator and, the yield was zero
articles but when combined with the Boolean operator or, 1270 articles were identified. Next,
“hospitalized patients” and “disruptive behavior prevention” resulted in zero articles while
“hospitalized patients” or “disruptive behavior prevention” yielded 785 articles. Finally,
“hospitalized patients” and all outcome terms resulted in zero articles while “hospitalized
patients” or all outcome terms yielded 2623 articles.
To better narrow the literature field, various intervention terms were combined with
various outcome terms. Intervention term “workplace violence” and the outcome term “patient
safety” resulted in eight articles that were then manually reviewed for relevance based on
inclusion criteria; of the eight, three pertained to the PICO(T) question under study. In searching
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PubMed, “workplace violence” and “patient outcomes” yielded 20 articles and a manual review
of those resulted in obtaining one article. “Disruptive clinician behavior” and “patient outcomes”
resulted in zero articles but “disruptive clinician behavior” alone resulted in 68 articles and a
manual review of those yielded two articles. The terms “incivility” and “patient outcomes”
resulted in four articles of which one pertained.
To be reasonably certain valuable research was not missed, a hand search was conducted
of three journals for articles pertaining to a culture of safety and adverse patient outcomes;
journals included were the Journal of Nursing Scholarship, JONA’s Healthcare Law, Ethics, and
Regulation, and the Journal of Advanced Nursing. Six articles were found from this hand search
but four were disregarded because they did not meet the inclusion criteria. This left two articles
but these had already been identified through the other search activities.
A Google Scholar web search was conducted using the various terms specified, however,
the resulting articles focused on nurse outcomes, such as retention and satisfaction, not patient
outcomes, so no useful material was found. In addition to the core studies ultimately identified,
multiple supportive articles were found during the search process that increases depth of
knowledge in related areas. A flow diagram of the search plan can be found in Appendix A.
Inclusion/Exclusion Criteria
Establishing inclusion and exclusion criteria to evaluate studies focuses a search to
promote the most relevant evidence (Melnyk & Fineout-Overholt, 2011). Full text availability
was a component of the inclusion criteria. Full copies of studies are highly recommended as this
allows repeated review for important details (Polit & Beck, 2012). In addition to full text
availability, the other inclusion criteria used in evaluating articles for this study were English
language, peer reviewed research, and publication within the last five years. Foreign language
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articles and articles published earlier than 2009 were excluded from consideration. Focusing a
search is critical to facilitating the most valuable evidence-based project outcomes. Also
important is being consistently mindful of the connection of search efforts to the patient. Raines
(2013) suggests that “knowing how to find evidence to support nursing practice behavior and
interventions is a professional responsibility and enhances patient outcomes” (p. 205).
Analyzing the Literature
An extensive search resulted in eight articles selected for this study. After conducting
critical appraisals of each article, one was discarded for content weakness in relation to the study
PICO(T) question. The seven articles remaining were carefully examined to determine
trustworthiness (qualitative research) and validity/reliability (quantitative research). A matrix
table was created to organize the article appraisal data. Headings were used for the matrix table
as applicable to qualitative or quantitative research articles and include: article citation and level
of evidence, purpose and conceptual framework, method of data collection and analysis,
measurement tools, sample and size, results, and summary comments. The matrix table can be
found in Appendix C.
Levels of Hierarchy of Evidence
The concepts and hierarchy of evidence described in Polit and Beck (2012) were used to
evaluate the types and strength of the evidence presented in each article. The hierarchy described
in Polit and Beck (2012) is designed as a seven-level pyramid with the highest point – Level I encompassing the strongest possible evidence which is systematic reviews of randomized control
trials (RCTs), followed by systematic reviews of nonrandomized trials. Level II includes single
RCTs and single nonrandomized trials, followed below by Level III containing systematic
reviews of correlational/observational studies. Level IV involves single
correlational/observational studies and Level V contains systematic review of
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descriptive/qualitative/physiologic studies. Nearing the base of the pyramid is Level VI,
composed of single descriptive/qualitative/physiologic studies and at the bottom is Level VII
evidence which is the opinion of authorities and expert committees. Overall, systematic reviews
of multiple studies are stronger than single studies within the same category. Of the seven
articles appraised for this study, two were Level VI evidence and five were level IV.
One caveat which Polit and Beck (2012) emphasize is that this hierarchy cannot be
universally applied for ranking evidence validity and is most appropriate for research questions
about the effects of clinical interventions. Polit and Beck (2012) note that the hierarchy would
not be relevant for questions related to the patient experience, however, that does not mean this
area is less important for nursing practice. Whether investigating efficacy, safety, and cost
effectiveness of nursing interventions; determinants of well-being; the nature of patient
experiences; or the quality of nursing assessment measures, the emphasis for determining best
evidence should be on findings that are methodologically appropriate, rigorous, and relevant for
the pressing clinical questions at hand (Polit & Beck, 2012). The focus of this study involves the
complexity of the lived clinician experience with behaviors that undermine a culture of safety
and how that potentially impacts patient outcomes, representing a newer focus for research
efforts.
Critical Appraisals
Laschinger (2014) conducted a single observational study that investigated “the impact of
subtle forms of workplace mistreatment (bullying and incivility) on Canadian nurses’
perceptions of patient safety risk and, ultimately, nurse-assessed quality and prevalence of
adverse events” (p. 285). The goal of Laschinger’s research was to see what effect workplace
bullying and incivility had on the perception of patient safety and adverse events. Laschinger
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used five different measurement tools in this study consisting of the Negative Acts Questionnaire
Revised (NAQ-R), the Cortina’s Workplace Incivility Scale, a 5-point Likert scale, a Sochalski
0-4 scale, and the Aiken et al 1-4 rating scale.
The results of the study showed that bullying and all sources of incivility were
significantly related to nurse-assessed quality of care, adverse events, and perceptions of patient
safety risk. Patient/family complaints were the individual adverse event most strongly related to
bullying and physician and coworker incivility. The study also revealed that subtle forms of
workplace mistreatments can have detrimental effects on patient safety outcomes. While there
are limitations to the study including use of cross-sectional data, low questionnaire response rate,
using a targeted sample, and patient outcomes being nurse-assessed, study methods demonstrated
sufficient rigor that the findings can be considered valid and reliable.
Flynn, Liang, Dickson, Xie, and Suh (2012) conducted a single observational study
examining “the relationships among characteristics of the nursing practice environment, nurse
staffing levels, nurses’ error interception practices, and rate of nonintercepted medication errors
in acute care hospitals” (p. 180). The goal of the Flynn et al. research was to examine whether or
not the environment that nurses work in contributes to the rate of nonintercepted medication
errors. The measurement tools used in this study were the Practice Environment Scale of the
Nursing Work Index (PES-NWI) and a four item scale on interception practices. The study
sample included 14 American acute care hospitals of various sizes in New Jersey, all designated
as teaching hospitals. Survey data was totaled to the unit level which was then linked with unit
level staffing and error data in order to understand the relationships among study variable.
Sample size included 82 medical-surgical units; critical care units and step-down units were
excluded.
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The results of the study demonstrated that a supportive practice environment prevents
medication errors. All subscales of the PES-NWI except for Staffing and Resource Adequacy
were positively associated with error interception practices. The subscales of Collegial NursePhysician Relationships and Foundations for Quality care were most strongly associated with
nurses’ interception practices. As the authors note, this study highlights that nurses in a
supportive environment demonstrate higher quality nursing practices. These practices include
interception behaviors which are associated with fewer adverse patient events.
The most significant limitation with this study is the use of incident reports for data
collection in relation to the well documented underreporting of medication errors or near misses.
A mean error rate below the national average appears to validate this concern; direct observation
or chart reviews are considered more reliable for studying medication errors and should be
considered for future studies. Another limitation concerns the tools used for measuring
interception practices in this study; although developed through extensive qualitative interviews,
further evaluation of reliability is needed. Despite stated limitations, the validity and reliability of
the study findings can be considered reasonably sound and lend support to the PICO(T) question
from the standpoint that supportive nurse practice environments are associated with less adverse
patient safety events.
The descriptive study by Chipps, Stelmaschuk, Albert, Bernhard, and Holloman (2013)
examined “whether the demographic variables of gender, ethnicity, hospital, years of experience
on the unit, years in the profession, and job title predict the experience of workplace bullying;
whether a relationship exists between workplace bullying and emotional exhaustion; and whether
bullying is associated with perceptions of patient safety in the OR” (p. 479). The goal of the
Chipps et al. study was to determine what effect bullying had in the operating room (OR). There
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were three measurement tools used in this study including the Negative Acts QuestionnaireRevised (NAQ-R), a nine item Emotional Exhaustion Subscale of the Maslach Burnout
Inventory (MBI) seven point Likert scale, and 23 additional questions.
This study used a cross-sectional survey design and a convenience sample of 167
participants including: RN’s, surgical technologists, and unlicensed perioperative personnel
working in the ORs. The participants were from two different academic medical centers that
were both Magnet designated. Using stated tools, the study measured workplace bullying,
emotional exhaustion, and the perception of job stress related to bullying experiences or the
witnessing on bullying. Data was analyzed using the SPSS Statistics computer software program
along with inferential statistics including: correlational analysis, multiple regressions, and
logistic regression analysis.
The results of the study demonstrated that 59% of study participants reported witnessing
coworker bullying weekly and 34% reported identifying at least two bullying acts weekly. The
most common act of bullying is identified as having one’s opinion ignored with 28% of
respondents reporting experiencing being ignored. Study results also show that while differences
in the experience of bullying is reported among varying hospitals and ethnicities, there is a
moderate, positive correlation between bullying and emotional exhaustion. Interestingly, only
6% of respondents indicated a perception that patient safety was compromised due to
experiencing negative acts, which is contrary to a variety of previous studies. While nearly twothirds of participants reported witnessing coworkers being bullied, less than one-tenth of
respondents identified themselves as being bullied. The authors note that the disparity between
observed and experienced bullying in relation to a low perception of patient safety compromise
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
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may be explained by bullying not being viewed as problematic, or by the result of a survey
limitation in question wording, using the term negative acts instead of bullying.
Other study limitations include survey length, voluntary participation, and a low response
rate, rising into question possible selection bias and representativeness of the results. The authors
note the possibility that those who have experienced bullying may have a greater desire to
participate or, alternatively, perpetrators may shun participation. In addition, the third tool used
questions developed by the authors. Although questions developed were peer-reviewed for
clarity, the questions may not have been completely effective in obtaining the information that
the authors were seeking.
Despite the limitations, reasonable validity and reliability can be inferred. While the
research relates to the focus of the PICO(T) question, the results do not support a relationship
between bullying and adverse patient safety events, however, a correlation between bullying and
emotional exhaustion was established. It is reasonable to think that this and other consequences
of bullying may impact quality nurse behaviors, ultimately affecting patient safety, but further
study is required. The authors recommend additional research to fully understand the
phenomenon of bullying and related consequences.
The single qualitative study of Walrath, Dang, and Nyberg (2010) examined the
experiences of hospital RNs related to disruptive behavior. The purpose of the study was to gain
understanding of how RNs describe disruptive clinician behavior and its perceived impact, based
on their observed and actual experiences. Focus group sessions involving 96 RNs from a variety
of practice settings within an acute care hospital were the mechanism for obtaining the data.
Findings revealed the occurrence of disruptive behavior in all practice settings, involving a
variety of healthcare personnel; 225 disruptive behavior events were coded and 168 different
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
23
disruptive behaviors were identified and synthesized into 21 categories. Three themes emerged
among these categories: incivility, psychological aggression, and violence. Physicians were
identified as instigators in 42% of events, nurses in 29% of events, support personnel in 27% of
events, and management in two percent of events. Triggers for disruptive behavior and RN
responses to disruptive behavior were also explored and the conceptual model Johns Hopkins
Model for Disruptive Clinician Behavior was presented.
The findings of Walrath et al. (2010) confirmed that disruptive behavior affects the RN,
the practice setting, and most importantly for the PICO(T) question being explored – the patient.
RN participants described emotional distress and distraction from patient care, and priority
conflicts between patient care and operational needs. Concerns regarding a decrease in quality
care, increased risk to patient safety, care delivery delays, and disrupted working relationships
were also described. There are limitations to this study that restrict the dependability and
transferability of learnings, such as convenience sampling with low response rate resulting in
participants not representative of the population of RNs employed at the organization and
inclusion of only a single study site. However, the credentials of the researchers are indicative of
adherence to scholarly research methods; rigor in conducting the study was demonstrated and the
study can be considered trustworthy.
Despite the study limitations, the experiences described by RN participants provide
insight into the disruptive behavior construct and provides direction for future inquiry of this
phenomenon in the acute care setting. This 2010 study by Walrath et al. supports the PICO(T)
question under examination, pointing to an emerging link between behaviors that undermine a
culture of safety - described in their study as disruptive clinician behavior - and adverse patient
safety events in acute care settings. The authors recommend increasing awareness and
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
24
establishing environments that recognize, acknowledge, and openly discuss disruptive behavior
in order to achieve a climate of civility as an important component of a culture of safety.
In follow-up work to their previous study, the purpose of the single correlational study by
Walrath, Dang, and Nyberg (2013) was to understand the complexities of disruptive behavior in
a large academic medical center in order to (a) determine type, frequency, scope, and impact of
clinicians’ personal experience with disruptive behavior; (b) compare the disruptive behavior
experiences of RNs and medical doctors (MDs); and (c) customize interventions for RNs, MDs,
interprofessional teams and the organization to improve the culture of patient safety. A survey
instrument entitled Disruptive Clinician Behavior Survey for Hospital Settings was developed
and appropriately validated to capture the data sought. A study population of 5,710 was targeted
that included three clinician groups made up of (a) RNs; (b) MDs; and (c) affiliates including
nurse practitioners, nurse midwives, and physician assistants. Ultimately, there were 1,559 study
participants.
Study findings demonstrated that 84% of respondents reported personally experiencing
disruptive behavior during the past year, with 26.4% reporting it was daily or weekly, 29.4%
reporting it was monthly, and 67% reporting that the behavior had been going on for a year or
more. In addition, 73% of respondents reported observing a coworker who was a target of this
behavior. RNs experienced a significantly higher frequency of disruptive behavior than MDs.
Disruptive behavior was reported more frequently within the MD staff and the affiliates reported
MDs as having the most negative impact. Of particular relevance to the PICO(T) question being
explored, there were 189 events of patient harm reported by participants related to disruptive
behavior, lending further emphasis that behaviors that undermine a culture of safety are
associated with adverse patient safety events in acute care settings. But interestingly, study
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
25
findings also indicate that MDs and RNs speak up when observing behavior that negatively
impacts patients and do not let the person exhibiting disruptive behavior present a barrier to
patient care and the reporting of patient deterioration which is in contrast to previous research
findings. Study findings also identified that disruptive behaviors have triggering events, such as
intrapersonal, interpersonal, or organizational in nature; participants specified organizational
triggers such as high census, volume, patient flow, environmental overload, and unresolved
system issues as the most frequently occurring, lending insight into where to target prevention
strategies.
There are some limitations to this 2013 study by Walrath et al. which constrain the
learning regarding the complexities of disruptive behavior under examination. Due to assessment
following the study that connotations of the term disruptive behavior may predispose how
respondents answered, the survey instrument was retitled to a more neutral phrasing: Survey of
Unprofessional Behaviors: Triggers, Responses, Impacts. Related to the findings that indicate
clinicians speak up and do not let disruptive behavior get in the way of patient care, the authors
acknowledge that the sensitivity of this survey item may have predisposed participants to
sacrifice accuracy of their responses in favor of one that would be perceived as more socially
acceptable. Lastly, a low response rate (possibly due to survey length and/or fear of being
identified), lack of data on non-responders, and the potential that responders were victims of
disruptive behaviors raise into question possible selection bias and representativeness of the
results. The authors have since shortened the survey instrument and decreased specificity of
demographic items in hopes to increase participation in future studies. However, based on the
credentials of the researchers as previously discussed and the rigor of survey instrument
development and methods, reasonable validity and reliability can be inferred. The authors note
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
26
that a culture of trust, mutual respect, and collegiality are the hallmarks of a culture of safety and
recommend organizational assessments to guide action planning to improve this important aspect
of the environment of care.
With an aim to relate nurses’ perceptions of violence on medical-surgical units (including
emotional abuse, threat, or actual violence) to the nurse practice environment and patient
outcomes, the single correlational observational study by Roche, Diers, Duffield, and CatlingPaull (2010) is a secondary analysis of data collected in two previous studies. A cross-sectional
collection of data was obtained by surveys, along with primary data collected for one week on 94
medical-surgical nursing units in 21 hospitals in two states of Australia. The Nursing Work
Index-Revised (NWI-R), the environmental Complexity Scale (ECS), the PRN-80 measure of
patient acuity, and survey questions on workplace violence were combined with primary data
regarding staffing, skill mix, and patient outcomes – specifically, falls and medication errors.
There were 2,487 participants, representing an 80.3% response rate.
Study findings indicated that while patients and families were the sources of most of the
perceived violence and emotional abuse, up to a fifth was reported to be from co-workers.
Findings related to patient outcomes revealed a positive association between physical violence
and falls, medication errors, and late administration of medication. In addition, threats of
violence were linked to both falls and medication errors. Although caution is warranted in
assimilating these associations due to the low rates for adverse events, the authors note some
correlations were supported by Poisson regression analyses specific to outcome measures with
low rates. In addition to the low adverse outcome rates limiting statistical power, the study was
also limited by self-reporting and a seven day data collection period which may have caused
some omissions in capturing adverse events. However, the credentials of the researchers are
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
27
indicative of adherence to scholarly research methods and the study was conducted with
sufficient rigor to consider it valid and reliable.
The study by Roche et al. pertains to the PICOT question being examined through
relating perceptions of violence in the acute care setting to the nurse practice environment and
patient outcomes. Violence is repeatedly an element for nurses to deal with in the environment of
care. The authors note that study outcomes point to perceptions of violence as more associated
with qualities of the work environment than with patient populations. The authors share that
“perceptions of violence were related to adverse patient outcomes through unstable or negative
qualities of the working environment” (Roche et al., 2010, p. 13). This study points toward
actionable items in the care environment that hospitals can address to improve a culture of safety.
The authors urge the importance of understanding the complexity of the care environment and
the relationship of violence to patient outcomes so meaningful change can be implemented.
In their single observational study, Wilson and Phelps (2013) explored horizontal
hostility (HH) in an acute care hospital. Relevant to the PICO(T) question under examination, the
aim of the study was to determine the perceived level of HH among nurses in one 220 bed
community hospital and, if present, determine the extent that HH behaviors (RN to RN or MD to
RN) directly influence nurse behaviors related to patient care and safety. A 28 item survey
instrument was developed, modeled after the American Association of Critical Care Nurses’
study entitled Seven Crucial Conversations in Healthcare and the survey by Stanley et al.
entitled Lateral Violence Nursing Survey. The survey instrument was distributed by members of
the hospital’s Nursing Research Council to all 500 RNs used by the hospital, excluding registry
and traveling nurses, in a two month period. The response rate was 26% (n = 130) with 80
respondents reported to be direct patient care providers and 17 were unit-based charge nurses; 11
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
28
were in indirect care roles and 22 chose not to identify their role. Once collected, completed
surveys were reviewed and transcribed by the PhD-prepared nurse researcher who was not
employed by the hospital or familiar with individual units or nurses. Descriptive statistics were
used to summarize demographic characteristics and item responses but inferential statistical
methods were not used because causation was not an intended focus of the study.
When asked about frequency of witnessing a peer or physician demonstrating bullying
behavior, results showed nearly 60% of respondents observed HH at least monthly, with a
majority of those stating it was weekly, with “nurse from my unit” then “a physician” as the top
two sources, followed by “a charge nurse”, and “a nurse from another department”. When asked
who they spoke with about perceived HH, 58% of participants spoke with coworkers while only
17.3% addressed the source directly. The most common reason for failure to confront was lack
of trust anything would change and that such a confrontation would only make their work
situation worse. Although response to the survey item addressing nurse behaviors in reaction to
HH was very limited, the authors were able to demonstrate a correlation between HH and
practice behaviors that compromise patient safety. For example, greater than 30% of respondents
indicated interpreting an unreadable physician order the best they could rather than calling to get
clarification.
Although author credentials and methods were commensurate with scholarly research,
development of the survey instrument was not fully explored and surveys were reviewed and
transcribed by a single (PhD-prepared) author. Major limitations were present in this study,
severely limiting validity and reliability, one of the most significant being the number of nurses
choosing not to answer several of the study variables which restricted the kinds of analyses
possible. Many nurses did not want to identify their home unit and the authors raise the
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
29
possibility that asking participants for this information was a design flaw. Although this thwarted
direct linkage of adverse events to levels of perceived hostility at the unit level, the authors urge
that until this happens, the full scope of HH on patient safety will not be understood.
Wilson and Phelps (2013) also hoped to examine nurse behaviors in response to HH in
relation to adverse events in order to establish a connection between HH and poor patient
outcomes but limited sample size in this survey section prevented the statistical power to do so.
Because of the limitations discussed and the single setting for the study, generalizability of
results is not possible. The overall low response rate raises into question selection bias,
prompting concern that participants were not representative of the population of RNs employed
at the organization and that participants were skewed toward those who had experience with HH
and wanted to share their account. Despite the many challenges, study results do indicate a
connection between HH and patient safety threats, and illuminate the need for further research in
this area.
Synthesis Discussion of Evidence
With an escalating climate of pay for performance, patient outcomes are an increasing
area of hospital concern and focus. When the Centers for Medicare and Medicaid Services
(CMS) began to cease payment for treating preventable hospital-acquired conditions such as
pressure ulcers, urinary tract infections, and blood stream infections; nurses received increased
education and training opportunities but also an increase in their workload without added
supports such as staffing or compensation (Buerhaus et al., 2012). The stressors on clinicians to
produce positive outcomes and prevent harm are great, particularly challenging given their
complex and dynamic work environment. While much has been done to improve clinical practice
to prevent hospital-acquired conditions, behaviors that undermine a culture of safety and their
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
30
influence on adverse patient events represents a newer area of exploration and one that must be
understood if hospitals are to become high-reliability organizations in their provision of
healthcare services.
New Understandings Generated by the Evidence
While direct correlation of behaviors undermining a culture of safety and adverse patient
safety events are only beginning to emerge, this systematic review of the most recent research
demonstrates a strengthening connection. Laschinger (2014) demonstrated that bullying and all
sources of incivility were significantly related to nurse-assessed quality of care, adverse events,
and perceptions of patient safety risk. Flynn et al. (2012) found that nurses in a supportive
environment demonstrate higher quality nursing practices including the use of interception
behaviors, and that a supportive practice environment helps to prevent medication errors. While
Chipps et al. (2013) did not determine a correlation between bullying and adverse patient safety
events, they did demonstrate a correlation between bullying and emotional exhaustion. It would
be logical to take the findings of Chipps et al. and interpret them inversely of the findings of
Flynn et al., hypothesizing that the emotional exhaustion related to bullying may compromise
patient safety through lower quality nursing practices which, in fact, is supported by the findings
of Walrath et al. (2010).
In Walrath et al. (2010), an emerging link was demonstrated between adverse patient
safety events and disruptive clinician behavior evidenced by RN respondent descriptions of
emotional distress and distraction from patient care. Also in Walrath et al. (2010) were concerns
regarding decreased care quality, increased risk to patient safety, and care delivery delays as a
result of disruptive clinician behaviors. These findings were also consistent with Wilson and
Phelps (2013) who were able to demonstrate a correlation between HH and behaviors that
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
31
compromise patient safety but were unable to demonstrate a link between nurse behaviors in
response to HH and adverse safety events due to their limited sample size, representing a
valuable area for future study.
Representing one of the larger, more comprehensive research efforts in this review,
findings in the follow-up study by Walrath et al. (2013) included 189 events of patient harm
reported by study participants as related to disruptive clinician behavior, providing one of the
few studies pointing to a direct association between the two variables. Roche et al. (2010) also
demonstrated a more direct correlation between undermining safety behaviors and adverse safety
events through a positive association between physical violence and falls, medication errors, and
late administration of medication, as well as threats of violence linked with both falls and
medication errors. While patients and families were found to be the main source of violence and
threats in the study by Roche et al., it is important to note that up to one-fifth of the incidents
reported were from coworkers. In addition, while the focus in organizations may tend to be on
hostile patients and families as sources of clinician abuse in the practice environment, Roche et
al. also found that perceptions of violence are actually more associated with qualities of the work
environment than with patient populations.
In addition to furthering insight into the effect of behaviors that undermine a culture of
safety on patient outcomes, this systematic review also expanded knowledge regarding other
aspects of the issue, including prevalence. Undermining safety behaviors were reported to occur
within many practice settings and may be more frequent than might have previously been
believed. Walrath et al. (2010) found disruptive behavior among all practice settings represented
by study participants. Chipps et al. (2013) found 59% of study participants witnessed coworker
bullying weekly and 34% reported identifying at least two bullying acts weekly. In Walrath et al.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
32
(2013), 84% of respondents reported personally experiencing disruptive behavior in the past
year, with 26.4% reporting it as daily or weekly, 29.4% reporting it was monthly, and 67%
reporting it had been going on for a year or more. Findings by Wilson and Phelps (2013)
demonstrated that 60% of respondents observed HH at least monthly. When envisioning the
amount of clinicians in a single hospital alone, the number of clinicians potentially exposed to
negative safety behaviors throughout the United States is stunning.
Additional insight from this review supporting greater understanding of the phenomena is
expanded awareness regarding types and sources of negative safety behaviors. Behaviors
undermining a culture of safety are expressed in many forms and involve a variety of personnel.
Walrath et al. (2010) identified 168 disruptive behavior types and synthesized the types into 21
categories; the three themes that emerged from these categories were incivility, psychological
aggression, and violence. The instigators of the disruptive behavior included physicians (42%),
nurses (29%), support personnel (27%), and management (2%). In Walrath et al. (2013), RNs
experienced significantly higher frequency of disruptive behavior than MDs and such behavior
was reported more frequently within the MD staff.
Participants that reported witnessing bullying behavior in the study of Wilson and Phelps
(2013) noted nurse within my unit, then physicians as the top two sources, followed by charge
nurse and a nurse from another department. While it might be natural to focus on the more
extreme circumstances, Laschinger (2014) highlighted the important distinction that even subtle
forms of workplace mistreatments can have detrimental effects on patient safety outcomes. This
is illustrated by the findings of Chipps et al. (2013) in which the most common act of bullying
was identified as having one’s opinion ignored, with 28% of the respondents reporting
experiencing being ignored. In settings where identification of risk requires team members at any
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
33
level to feel free to speak up and others to actively listen in order to prevent errors from reaching
the patient, these findings are highly concerning and should cause healthcare organizations to
take notice.
Causation is only beginning to be examined but is important to identifying remedies and
this systematic review provided new insights in this area, as well. Walrath et al. (2013) found
that disruptive behavior has triggering events that are intrapersonal, interpersonal, or
organizational in nature; study participants identified organizational triggers such as high census,
volume, patient flow, environmental overload, and unresolved system issues as the most
frequently occurring. Hospitals need to better understand how their workflow decisions in
response to organizational pressures might have more subtle but substantial negative downstream
consequences unless there are mitigating strategies to improve the practice environment and
promote safety. The Social Learning Theory and the Nursing Oppression Theory can help inform
understanding about why these behavioral responses occur and tools such as the Survey of
Unprofessional Behaviors: Triggers, Responses, Impacts can assist organizations in assessing
their individual settings in order to make meaningful action plans to improve their safety culture.
Limitations
This review study was impacted by the fact that the topic is a newer area of exploration
and, as such, the volume of evidence that is currently available is limited. While most of the
research reviewed strengthened the perception of an association between behaviors that
undermine a culture of safety and adverse patient safety outcomes, only two of the studies were
able to establish a direct correlation. The focus represents a particularly challenging area to
conduct research for a variety of reasons, one of which is the sensitivity of the subject matter
which may constrain the acquisition of willing study participants representative of the study
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
34
population, as well as confound the development of study designs that facilitate objective data
collection. Those investigators who have already embarked on the journey should be appreciated
and the learnings from these pioneers will influence subsequent research, eventually allowing a
rich understanding of this important area to patient safety.
Implications/Impact of the Evidence
This review study underscores understanding that clinician behavior matters to patient
safety. The primary implication of this study for hospitals and those who serve within them is the
need to appreciate the effects of a hostile work environment on patient outcomes, and embrace a
priority to assess and address those issues to promote a culture of safety. Hospitals are dynamic
environments with differences in hierarchy and disciplinary structures among the various
professions that make up the healthcare team; this complexity presents challenges in building a
culture of patient safety (Manojlovich et al., 2014). An intervention plan may seem daunting but
resources exist to aid in the effort. The Joint Commission provides a blueprint of
recommendations that organizations can implement to address behaviors compromising a culture
of patient safety, including the areas of

recognition and awareness;

cultural commitment/leadership/champions;

policies and procedures;

incident reporting;

structure and process;

initiating factors;

education and training;

communication tools;
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY

discussion forums; and

intervention strategies (Rosenstein & O’Daniel, 2008, p. 468-470).
35
Ensuring a healthy work environment to promote safety is the right thing to do for the primary
stakeholder, the patient, but it is also the right thing to do for the well-being of those who are
entrusted to provide care. However, other implications of this review study exist, as well,
supporting the need to optimize patient safety through positive work cultures.
There are financial ramifications in allowing behaviors undermining patient safety to
persist. In supporting literature, Becher and Visovsky (2012) shared Gerardi and Connel’s
estimates that horizontal violence is estimated to cost $30,000-$100,000 annually for each victim
through absenteeism, treatment for depression and anxiety, decreased work performance, and
increased turnover; they also shared Pendry’s replacement cost estimate of one specialty nurse
possibly exceeding $145,000. Particularly critical with nursing as the largest profession involved
in healthcare, nursing workforce attrition reduces the quality and quantity of care provided with
significant implications for health outcomes (Huntington et al., 2011). The relationship between
nursing and care quality needs to be appreciated, particularly now when recruitment and
retention of talent is vital; hospitals and the United States overall cannot afford to be shortsighted in this regard.
As a top occupation for job growth, the RN workforce is expected to grow 19% by 2022
to 3.24 million and the nursing shortage is expected to grow to 260,000 by 2025, representing a
shortage twice as large since the mid-1960s (American Association of Colleges of Nursing
[AACN], 2014). There seems to be a significant gap between knowledge of the practice
environment, recommendations for change and change occurring, resulting in nurses intending to
leave the profession (Huntington, et al., 2011). Hospitals must do all they can to retain and
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
36
recruit a robust nursing workforce, being ever mindful that, in addition to filling vacancies, these
efforts have an important impact on patient well-being. This review study expanded knowledge
of the practice environment and provided evidence that destructive clinician behavior affects
many facets of care delivery, all of which can negatively impact patient safety.
The call to do no harm is the guiding principle for all healthcare professionals and, yet, it
continues to occur. In addition to related hardship experienced by the patient, another
organizational consequence to lack of a safety culture is the burden of cost associated with
patient harm. Previously, costs to Medicare for hospital acquired conditions was in the billions
annually; CMS reported 29,536 vascular catheter-associated infections in 2007 resulting in an
average cost of $103,027 per hospitalization totaling over $3 billion (Himes & Yu, 2009). With
the Affordable Care Act and the current pay for performance climate, these costs are increasingly
shifting to the provider; combined with costs related to legal actions associated with poor patient
outcomes, there is increasing urgency for financial reasons alone to ensure high quality care.
This review study helps to illuminate that, along with clinical strategies, a focus on clinician
behaviors needs to be included in the repertoire of evidence-based action items important to care
quality; the benefit can be expected to far outweigh the cost of not doing so. In alignment with
other influential healthcare organizations, Safety and Teamwork and Collaboration are included
as two of the Quality and Safety Education in Nursing (QSEN) competencies (AACN, 2012),
lending emphasis that effort in this area should be a priority.
Future Recommendations about Nursing Research
The area of clinician behaviors undermining to a culture of patient safety represents rich
ground for future study. Chipps et al. (2013) recommend additional research to better understand
the phenomenon of bullying and related consequences. The issue actually encompasses many
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
37
behavior types including bullying, hostility, incivility, disruptive behavior, and lateral/horizontal
violence and each once should be fully explored. Nurse practice behaviors, in response to
negative clinician behaviors, is another area that needs to be thoroughly examined in order to
confidently understand the impact on patient safety. Wilson and Phelps (2013) highlighted the
need to connect adverse events to perceived hostility at the unit level in order to better establish a
direct correlation to patient safety.
The issues of behaviors that undermine a culture of safety in relation to adverse patient
events cannot be studied in isolation since the lived experience of clinicians - their perceptions,
reactions, and response behaviors - are complex, as are the organizations in which they work. As
systems within the body can affect each other in profound ways for good or ill, patient safety is
significantly impacted by the practice environment through those providing their care. In Roche
et al. (2010), the authors encourage greater understanding regarding the complexity of the care
environment and the relationship between clinician behaviors and patient outcomes so
meaningful change can happen. This understanding should also be extended to include causation
which is only beginning to be explored and is the key to hospitals establishing supportive
systems and standards, in appreciation that healthier practice environments lead to safer patients.
Future Recommendations about Nursing Education
The findings of this study indicate that the opportunities for nursing education within the
realm of this issue are broad. In relation to nurses speaking up in the face of hostility, findings
were mixed. For example, while participants in Walrath et al. (2013) reported 189 events of
patient harm related to disruptive behavior, findings also indicated that clinicians speak up in the
face of disruptive behavior and do not let it interfere when patient safety is at risk (in contrast to
earlier research). On the contrary, the findings of Wilson and Phelps (2013) indicated a lack of
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
38
confronting behaviors and demonstrated a correlation between HH and practice behaviors that
compromise patient safety. Other findings such as those by Chipps et al. (2013), point to the
possibility that bullying is not viewed as problematic. In supporting literature, Lachman (2014)
discussed the Code of Ethics for Nurses as established by the American Nurses Association
(ANA), noting that these standards clearly define intimidating behavior as unethical and outline a
nurse’s responsibility not to engage in those behaviors and to act on circumstances to the
contrary. Therefore, areas of staff education should include; behavior standard expectations,
behavior recognition, conflict resolution, communication and assertiveness training, available
organizational resources, actions to take when such behavior is encountered, how to document
such behavior, and the overall connection to patient safety.
Future Recommendations about Nursing Administration
The recommendations for nursing administration based on this review study are
significant. Hospitals are inherently complex, stressful work environments; between worried
customers and their families who do not want to be there in the first place to the challenges
experienced by those who care for them, including varied work hours, variable resources, and
often perceived lack of recognition, the potential consequences of a negative hospital culture on
productivity, patient satisfaction, and patient safety are enormous (Huseman, 2009). Hospital
culture is largely established from the top down and nurse administrators have primary
responsibility in establishing environments that promote wellness of patients and staff members.
If expectations are not set promoting an optimal culture of safety with a climate in which all
clinicians are held accountable to those expectations, departments will establish their own
cultures and, unfortunately, ones not always in the best interest of patients, clinicians, and the
organizations in which they serve. The ANA Code of Ethics outlines the responsibility of nurse
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
39
leaders to implement and enforce policies, processes, and education to correct behaviors
undermining a culture of safety (Lachman, 2014). Nurse leaders must require a positive practice
environment; they need to be skilled at crucial conversations in order to do so, as well as role
model the behavior expectations they seek to enforce.
Administrators should take note that the evidence demonstrates a priority to establish
environments that recognize, acknowledge, and openly communicate to achieve a climate of
civility as an important component to patient safety (Walrath, 2010). Administrators should
know the climate that exists in their organizations through a lens of understanding that a culture
of trust, mutual respect and collegiality are hallmarks of a safety culture; they should conduct
organizational assessments to guide action planning (Walrath, 2013). In supporting literature,
McNamara (2012) acknowledges the potential harmful effects of incivility on patients and
recommends equipping nurses with anti-bullying tools, including (a) organizational resources,
(b) education, (c) expectations to role model appropriate behavior, and (d) not allowing such
behavior to go unaddressed. Administrators need to make resource allocation decisions
supporting a positive safety culture but they cannot expect to do so on their own; their actions
must empower others in establishing and maintaining a culture of civility and safety throughout
all levels of the organization if such a culture is to be sustained.
Future Recommendations about Nursing Practice
This review study confirmed an increasing association between behaviors undermining a
culture of safety and adverse patient outcomes. Undermining safety behaviors, if left unchecked,
can create a negative practice environment that spreads just as readily as an aggressive cancer,
sickening more and more of the organization and ultimately harming patients. People tend to
remember failure more than success, react more strongly to negative stimuli than positive, and
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
40
trust negative information more than positive (Huseman, 2009). Hospital culture in many ways
has taught nurses to tolerate, even accept incivility as an unavoidable aspect of the profession –
this needs to change going forward. While nurse leaders should establish the framework for a
required safety culture through education, behavior standards, and accountability, each
individual nurse must embrace the evidence linking uncaring behaviors to patient safety and take
personal responsibility in their own practice to create care environments that support wellness.
Conclusion
The emphasis for hospitals to ensure positive patient outcomes is stronger than ever
before. While significant evidence exists regarding the impact of clinician behavior on nurse
outcomes such as satisfaction and retention, the purpose of this evidence-based review was to
better understand the impact of clinician behaviors that undermine a culture of patient safety on
patient outcomes. After an extensive search, critical appraisals were conducted of seven research
articles meeting the inclusion criteria. Results demonstrate emerging evidence supporting
clinician behavior as a critical element to safety culture and it should no longer take a back seat
when setting strategic priorities to enhance patient safety. Hospitals need to assess their cultures
and address destructive behavior patterns in order to do what is best for patients, employees, and
their bottom line. More research is needed regarding the complexity of care and all aspects of the
clinician behavior construct, particularly the direct impact on adverse patient events; these efforts
will enrich understanding and support meaningful decision making to improve safety. Huseman
(2009) suggests “It is the virus of negativity that must be battled in order to help sick hospitals
become well. Only a positive culture can secure the health and wellness for a hospital, its
employees and its patients” (p. 63). Through continued research, education, ownership, and
personal accountability on the part of the entire healthcare team to remedy behaviors
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
41
undermining to a culture of safety, positive outcomes for patients and all involved can be
significantly strengthened. If there is a will and a commitment to do so, healthcare can achieve
and exceed the high-reliability of the airline industry; focus on behaviors undermining a culture
of safety is an important aspect in achieving that goal.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
42
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Walrath, J., Dang, D., & Nyberg, D. (2010). Hospital RNs' experiences with disruptive behavior:
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BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Appendix A
Search Flow Diagram
47
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
48
Among hospitalized patients in acute care settings, how do behaviors that undermine a culture of
safety compare to the absence of behaviors that undermine a culture of safety, affect the
occurrence of adverse patient safety?
Search completed in databases Pub MED (PM) and CINAHL Plus (CNL)
Hand search: Journal of Nursing Scholarship, JONA’S Healthcare Law, Ethics, and
Regulation, and Journal of Advanced Nursing.
Inclusion: Full Text available, Language- English, published in the last 5 years, reviewed,
CINAHL Plus- Research
Exclusions: Foreign language articles, Articles earlier than 2009.
Population
Intervention
Comparison
Outcome
Hospitalized
patients
PM 813
CNL 754
Lateral violence
PM 5
CNL 11
Disruptive
behavior
prevention
PM 10
CNL 31
Patient
safety
PM 4774
CNL 2223
Workplace
violence
PM 30
CNL 188
Medication
errors
PM 393
CNL 549
Incivility
PM 3
CNL 40
Combined
using “or”
785
Hostility
PM 71
CNL 113
Disruptive
behavior
PM 130
CNL 191
All combined
using “or”
1270
Combined
using “and”
0
All combined
using “and” 0
All combined
using “and” 0
All combined using “or”
3336
Patient Falls
PM 600
CNL 41
Wrong site
surgery
PM 17
CNL 14
All
combined
using
“and” 0
All
combined
using “or”
2623
Hand
Search
All terms
6
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Appendix B
Critical Appraisals
49
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
50
Critical Appraisal of Qualitative Research Form
Citation: Walrath, J. M., Dang, D., & Nyberg, D (2010). Hospital RNs’ experiences with
disruptive behavior: A qualitative study. Journal of Nursing Care Quality, 25(2), 105-116.
doi:10.1097/NCQ.0b013e3181c7b58e
Purpose: The purpose of the study was to conduct focus groups with RNs to gain an
understanding of how RNs describe disruptive clinician behavior and its impact based their
observed and actual experiences on the front lines of patient care delivery.
Level of evidence: Single Qualitative Study-Level VI
Study trustworthiness: Use Polit and Beck pages 509-510 and 576-577 to complete this table.
Aspect of study
Problem and research
questions
Comments of strengths and weaknesses
Disruptive clinician behavior and the potential effects on
organizational culture, nurse satisfaction, and patient
safety and care quality are growing concerns that need to
be addressed. What are RNs’ perceptions regarding the
characteristics of clinician disruption behavior and what
is the perceived impact based on their observed and
actual experiences in a patient care setting?
Theoretical base:
Literature review
completed, conceptual
underpinning
Literature review reveals that disruptive behavior is
prevalent in healthcare. Joint Commission issued a 2008
Sentinel Event Alert in response to growing recognition
that disruptive behavior negatively impacts care quality
and patient safety. Regulatory standards now require
organizations to have a code of conduct and a process
for managing negative behaviors. Despite numerous
disruptive behaviors reflected in the literature, most
have inconsistent or imprecise definitions. Disruptive
behavior is a complex construct and full understanding
requires examination of causes, individual responses,
effects on individuals and organizations, and perceptions
of harm to patients. However, the researchers found no
conceptual framework that included these interrelated
concepts in a meaningful way. The researchers adapted
Pearson and colleagues’ framework on workplace
incivility and developed a framework for organizing and
describing disruptive behavior, which included 4
primary concepts: triggers, disruptive behaviors,
responses, and impacts.
Ethical issues
Design and tradition
No ethical issues were identified.
Descriptive qualitative study – no specified tradition
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Sample and setting
Purposive convenience sampling of 96 RNs in an acute
care hospital within an academic medical center located
in the Northeastern United States. The recruitment
process invited participation through information of the
study distributed across the Department of Nursing via
posters, internal Web sites, and individual letters to RNs
(N = 2467). 32.3% of participants were nurse managers
and shift coordinators; 52% were staff nurses; 15.6%
were advanced practice nurses. 95% of participants were
female. 70.8% were white; 12.5% were Asian; 9% were
black; 3.1% were Hispanic/Latino.
Data collection and
procedures
IRB approval and oral consent from participants
obtained. A clinical psychologist external to the
organization facilitated 90-minute focus group sessions,
using semi structured interview questions based on the
conceptual framework. Focus group size was from 7 to
14 RNs. Pseudo names were used when describing
individuals involved in disruptive behavior events to
ensure confidentiality of sensitive information. The
sessions were audio-recorded and held between January
and March 2008.
Rigor
Reasonable rigor was demonstrated; credentials of
researchers indicative of adherence to scholarly research
practices.
Data analysis
The recorded sessions were transcribed verbatim and
validated for accuracy against the original recordings.
Nudist6 software program designed for narrative
analysis was used to manage the interview data and
facilitate the coding process. Deductive and inductive
processes were used to code the data. Two members of
the research team independently assigned codes to text
segments of the transcribed interviews. After reaching
consensus on the codes through comparison and
discussion, the full research team was convened to
review, identify patterns, and synthesize the initial codes
into broader categories. These categories were further
synthesized into major themes and organized according
to the 4 primary concepts in the conceptual framework.
Findings and theoretical
integration
Participants reported the occurrence of disruptive
behaviors in all practice settings and between /among a
wide variety of healthcare personnel. 168 different
disruptive behaviors were identified and then
51
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
synthesized into 21 categories. Within these categories,
3 themes emerged: incivility, psychological aggression,
and violence. The 10 most frequently identified
categories within these themes were rude/disrespectful
(Incivility); engaging in gossip, intimidation/threats,
passive aggressive behavior, refusal to do one’s job,
verbal aggression, power play, condescending
language/dress down, professional disregard
(Psychological aggression); and physical violence
(Violence). Out of the personal experiences reported,
225 disruptive behavior events were coded. Physicians
were identified as instigators in 42% of events; nurses in
29% of events; support personnel in 27% of events; and
management in 2% of events. Triggers, RN responses,
and impacts on the RN, patient, and nurse’s practice
setting were also identified.
Interpretations,
implications and
recommendations
This study adds evidence that disruptive behavior has
been observed or experiences throughout all levels of
nursing and among major professional groups. In
addition to RNs and MDS, support personnel were
identified as instigators and targets. The impact on the
organization increases as the roles and numbers of
individuals involved in disruptive behavior grows.
Disruptive behavior affects the RN, patient, and the
practice setting. Distraction from patient care, physical
and emotional distress, and priority conflicts between
patient care and operational needs were described by the
RN participants. Concerns regarding a decrease in
quality care, increased risk to patient safety, care
delivery delays, and disrupted working relationships
were also described.
Recommendation: Increasing nurse leaders’ and staff’s
awareness and creating an environment in which
disruptive behavior is recognized, acknowledged, and
openly discussed are important steps in establishing a
culture of civility and patient safety.
Global issues
See literature review section above.
Overall Comments from analysis: (speak to credibility, dependability, transferability &
confirmability)
52
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
53
Credibility: (confidence in the truth) The study was limited to RNs due to the funding agency’s
requirements which limits representativeness of the findings; while there is no reason to question
the validity of findings among the participants, results and understanding of the issues could be
enhanced by wider participation among diverse groups of healthcare professionals.
Dependability: (stability over time) Convenience sampling of volunteers resulted in participants
not representative of the population of RNs employed in the organization. Participants were
older, more experienced, more educated, and less diverse than the body of nursing staff where
this study was conducted. A 3.9% response rate and the potential that participants were victims
of disruptive behavior over the course of their careers and were more ready to share their
experiences raises the possibility of selection bias.
Transferability: (to other settings) Findings from study focus groups represent RNs experiences
and observations in an academic medical center and may not be representative of experiences in
other hospital settings.
Confirmability – (objectivity or neutrality of the data and interpretations) The linear relationship
of the variables presented in the conceptual framework influenced the researchers’ approach to
the data collection and also may have influenced the analysis of the qualitative data. Further
exploration of the interdependencies and relationships among the 4 framework concepts would
deepen understanding.
Despite the study limitations, the lived experiences described by RN participants provide insight
into the disruptive behavior construct and provides direction for future inquiry of disruptive
behavior in acute care settings.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
54
Critical Appraisal of Quantitative Research form
Citation: Chipps, E., Stelmaschuk, S., Albert, N. M., Bernhard, L., & Holloman, C. (2013).
Workplace bullying in the OR: Results of a descriptive study. AORN Journal, 98(5), 479-493.
http://dx.doi.org/10.1016/j.aorn.2013.08.015
Study purpose or research questions: “The study sought to determine whether the
demographic variables of gender, ethnicity, hospital, years of experience on the unit, years in the
profession, and job title predict the experience of workplace bullying; whether a relationship
exists between workplace bullying and emotional exhaustion; and whether bullying is associated
with perceptions of patient safety in the OR” (Chipps, Albert, Bernhard, and Holloman, 2013,
p.1).
Level of evidence: Level VI- descriptive study
Study validity: Use your research text to guide you in determining bias in the following steps
of the research process (Polit and Beck pages 230-231.
Validity
analysis
criteria
Problem and purpose
statements
Mark an x
if very
serious
concerns
Your comments re major strengths and weaknesses
The problem in the study is workplace bullying in
the OR.
The purpose of this study was to:
Describe the incidence of workplace bullying
among perioperative RNs, surgical technologists,
and unlicensed perioperative personnel at two
academic medical centers
Determine whether the demographic variables of
gender, ethnicity, years of experience on the unit,
years in the profession, and job title predict the
experience of workplace bullying
Determine whether there is a relationship between
workplace bullying and emotional exhaustion
among perioperative staff members
Determine whether workplace bullying is
associated with perceptions of patient safety in the
OR
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Theoretical base from
lit review and
conceptual framework
and concept
definitions
This study used a model of bullying from
Hutchinson et al. In this model “organizational
antecedents” must be present for bullying to exist
in the work environment.
Bullying includes terms of workplace incivility,
disruptive behaviors, peer incivility, horizontal
violence, and lateral violence.
Design
Cross-sectional survey.
Ethical issues
No ethical issues were identified
Sample and setting
 Inclusion and
exclusion
criteria
 Selection
method
(random
selection or
assignment,
convenience
 Size of n
Included RNs, surgical technologists, unlicensed
perioperative personnel working in ORs at two
academic Magnet medical centers
Measurement tools
*Negative Acts Questionnaire- Revised (NAQ-R)22 items.
Cronbach alpha scores ranging from 0.81 to 0.92
Exclusion criteria included employment for fewer
than six months on the unit and less than a 50%
work week
n= 167
*Nine item Emotional Exhaustion Subscale of the
Maslach Burnout Inventory (MBI) Seven point
Likert scale 0-6, never to daily, scores split and
coded into 0-16-low, 17-26-moderate, 27 or morehigh. Cronbach alpha score 0.91.
*23 additional questions including eight
demographic questions, eight questions related to
bullying experiences and witnessing bullying
behaviors at work, and seven questions about the
effect of bullying on near errors, errors,
expectations, and safety of patients. Nurse experts,
clinical nurse specialists, nurse administrators, and
staff nurses reviewed questions for clarity.
55
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Data collection
After receiving institutional review board approval
at both hospitals, the research team met with staff
to introduce the study. Surveys were put in
mailboxes of all eligible participants with cover
letters stating that potential participants could opt
out by simply not returning the survey.
Procedures
The return of the survey implied consent.
Enrollment lasted for 1 month. At hospital A
surveys were returned via sealed envelope in a
locked box in the break room. Hospital B surveys
were given preaddressed envelopes to be returned
to the hospital principal investigator via interoffice
mail.
Data analysis
SPSS Statistics software to analyze the data.
Inferential statistics, correlational analysis,
multiple regression, and logistic regression
analyses.
Findings (discussion
of results) and
Demographic differences were significant between
hospitals.
Interpretation of
findings : conclusions
of what is true ,
implications of
conclusions
Approximately one-third of participants would be
characterized as targets of workplace bullying.
59% reported witnessing coworkers being bullied
6 % reported they never experienced bullying on
all 22 items
Perpetrators
Other employees on unit 56%
RNs on their unit 56%
Physicians 44%
RN managers 33%
Charge RNs 11%
Hospital A almost 3 times more likely to be a
target for bullying than Hospital B
White respondents reported bullying intensity
scores 3.8 points higher than black respondents
and 4.7 points higher than “other” respondents
A significant moderate, positive correlation among
56
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
57
bullying frequency, bullying intensity, and
emotional exhaustion exists.
A moderate, negative correlation of bullying
frequency, bullying intensity, and job satisfaction
exists.
3% indicated that bullying affected errors and
perceptions of patient satisfaction.
6% indicated that bullying affected patient safety
Respondents associated 8 negative acts with
perceived compromises in patient safety
Recommendations
based on implications
Further descriptive research on workplace bullying
in the OR. Interventions to ameliorate workplace
bullying. Incorporate workplace bullying messages
into training programs.
Presentation
Association of Peri Operative Registered Nurses
(AORN) journal.
Credentials of the
researcher
Chipps PhD, RN
Stelmaschuk BSN, RN
Albert PhD, CCNS, CHFN, CCRN, NE-BC,
FAHA, FCCM
Bernhard PhD, RN
Holloman PhD
Assessment of
validity of findings.
There were 3 tools used. The first two tools are
established measurement tools and measure what
they are supposed to measure. The third tool used
questions made up by the authors, these questions
were peer-reviewed for clarity but the questions
may have not specifically answered what the
authors were trying to get answered.
Study Reliability: The consistency of the tools used is good so reliability would be good.
What are the results? What are the statistical answers to the research questions (statistical
significance)?
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
58
NAQ-R behavior Monthly Weekly Daily Total
Having your opinion ignored 13.3% 8.5% 6.1% 27.9%
Being shouted at 14.5% 10.2% 2.4% 27.1%
Withholding information that affects your performance 8.6% 11.0% 6.7% 26.3%
Being humiliated or ridiculed 10.3% 11.5% 3.6% 25.4%
Having gossip or rumors spread about you 7.4% 9.3% 8.6% 25.3%
Ordered to do work below your competency level 6.8% 6.8% 9.3% 22.9%
Being ignored or isolated from the rest of the work group 6.7% 11.0% 3.7% 21.0%
Being ignored or facing hostility when you approach 10.4% 6.1% 2.4% 18.9%
Insulting or offensive remarks about you 5.5% 6.1% 5.5% 17.1%
Key areas of responsibility replaced with trivial/unpleasant tasks 4.9% 8.6% 3.1% 16.6%
Excessive monitoring of your work 5.6% 6.8% 3.1% 15.5%
Persistent criticism of your work 6.1% 5.5% 3.0% 14.6%
Assigned tasks with impossible deadlines 12.0% 10.0% 2.0% 24.0%
Unmanageable workload 6.1% 6.1% 1.8% 14.0%
Repeated reminders past of errors 7.3% 4.3% 1.8% 13.4%
Pressure to give up what you are entitled to (eg, sick time, vacation) 6.7% 4.3% 1.8% 12.8%
Subject of constant teasing or sarcasm 5.5% 3.0% 4.2% 12.7%
Practical jokes carried out by people you get along with 5.5% 1.8% 4.3% 11.6%
Intimidating behavior such as shoving or finger-pointing 4.9% 3.7% 2.4% 11.0%
Having allegations made against you 6.1% 2.4% 2.4% 10.9%
Hints to quit your job 2.4% 2.4% 0.6% 5.4%
Threats of violence and physical abuse 2.4% 0.6% 0.6% 3.6%
Average number of bullying acts that participants experienced more often than never (ie,
intensity) was 9.7 (SD 6.38)
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
59
Average of 2.1 (SD 3.75) acts weekly or daily (ie, frequency)
Most frequently experienced acts occurring weekly or daily were having rumors or gossip spread
(50%), being ordered to work below competency level (46.3%), being humiliated (45.4%),
having information withheld (43.6%), and being excluded (41.8%).
A significant moderate, positive correlation among bullying frequency (rho .56, P < .001),
bullying intensity (rho .54, P < .001), and emotional exhaustion exists.
There is a moderate, negative correlation among bullying frequency (rho e.31, P < .001),
bullying intensity (rho e.29; P < .001), and job satisfaction.
Eight negative acts in this study with perceived compromises in patient safety
impossible deadlines (odds ratio 2.4 [95% CI, 1.4-4.0])
having opinions ignored (odds ratio 2.3 [95% CI, 1.4-3.7])
having false allegations made (odds ratio 2.0 [95% CI 1.2-3.3])
excessive monitoring of work (odds ratio 2.0 [95% CI, 1.2-3.1])
hints from others that the respondent should quit his or her job (odds ratio 1.9, [95% CI, 1.0-3.5])
being reminded of errors or mistakes (odds ratio 1.8 [95% CI, 1.1-3.0])
being humiliated at work (odds ratio 1.8 [95% CI, 1.1-3.0])
being the target of practical jokes (odds ratio 1.7 [95% CI, 1.1-2.8]).
What is the clinical significance of the results? The clinical significance of the results is that
workplace bullying was shown to affect the perception of compromised patient safety.
Applicability: This was an OR study which can limit the applicability to lower stress units of
care.
Overall Comments on validity and reliability: There are limitations to this study since crosssectional data was used and precludes attribution of cause and effect among the study variables.
The low questionnaire response rate of 28.7% also is limiting.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
60
Critical Appraisal of Quantitative Research form
Citation: Flynn, L., Liang, Y., Dickson, G. L., Xie, M., & Suh, D. (2012). Nurses' practice
environments, error interception practices, and inpatient medication errors. Journal of Nursing
Scholarship, 44(2), 180-186. doi:10.1111/j.1547-5069.2012.01443.x
Study purpose or research questions: “to determine the relationships among characteristics of
the nursing practice environment, nurse staffing levels, nurses’ error interception practices, and
rate of nonintercepted medication errors in acute care hospitals” (Flynn, Liang, Dickson, Xie,
and Suh, 2012, p 180).
Level of evidence: Level IV- single observational study
Study validity: Use your research text to guide you in determining bias in the following steps
of the research process (Polit and Beck pages 230-231.
Validity
criteria
analysis Mark an x
if very
serious
concerns
Problem and purpose
statements
Your comments re major strengths and weaknesses
Problem- medication errors
Purpose- “to determine the relationships among
characteristics of the nursing practice environment, nurse
staffing levels, nurses’ error interception practices, and
rate of nonintercepted medication errors in acute care
hospitals” (Flynn, Liang, Dickson, Xie, and Suh, 2012, p
180).
Theoretical base from
lit review and
conceptual framework
and concept
definitions
Reason’s error theory
Design
Correlational
Ethical issues
No ethical issues- reviewed by Rutgers University
Institutional Review Board and IRBs of participating
hospitals.
Sample and setting
 Inclusion and
exclusion
criteria
Inclusion- survey participants be registered nurses
employed in a position of staff nurse on their unit.
Exclusion- float staff not included.
All nurses that met inclusion criteria were invited to
The Nursing Organization and Outcomes Model- link
between the presence of characteristics in the
environment that support professional nursing practice
and positive patient outcomes.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY


Selection
method
(random
selection or
assignment,
convenience
Size of n
Measurement tools
61
participate.
n= 686
*PES-NWI
*Four item scale of interception practices
Data collection
8 month period- number of medication errors per 1000
patient days and the number of RN hours per patient day.
Nurse surveys distributed and collected by study liaison.
Procedures
Participants given written document- informed consent,
description of study, study purpose, and rights as research
subject.
Mean response rate 96%
Data analysis
Correlation coefficients computed between variables
Findings (discussion
of results) and
Interpretation of
findings : conclusions
of what is true ,
implications of
conclusions
Recommendations
based on implications
A supportive practice environment was positively
associated with error interception practices among nurses
in the sample of medical-surgical units. Importantly,
nurses’ interception practices were inversely associated
with medication error rates.
Presentation
Journal of Nursing Scholarship
Credentials of the
researcher
Flynn PhD, RN, FAAN
Liang PhD
Dickson PhD, RN
Xie PhD
Suh PhD
The validity of the findings is sound. The studies
evaluating methods are measuring the concepts that they
are trying to measure.
Assessment of validity
of findings.
Nurses need supportive environments to intercept
medication errors.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
62
Study Reliability: The consistency of the tools used is good so reliability would be good.
What are the results? What are the statistical answers to the research questions (statistical
significance)?
Variable
β
SE
df
t
p
Nurses’ interception practices
−0.19 0.08
73.98 −2.48 .015
Nursing practice environment
−0.26 0.30
79.95 −0.87 .388
composite score
What is the clinical significance of the results? If nurses have a supportive environment they
employ practices that can assist in interrupting medication errors before reaching the patient.
Applicability: Study is applicable with the high number of medication errors.
Overall Comments on validity and reliability: The biggest problem with this study is the use
of incidence reports and the underreporting of medication errors or near errors.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
63
Critical Appraisal of Quantitative Research form
Citation: Laschinger, H. K. (2014). Impact of workplace mistreatment on patient safety risk and
nurse-assessed patient outcomes. Journal of Nursing Administration, 44(5), 284-290.
doi:10.1097/NNA.0000000000000068
Study purpose or research questions: “To investigate the impact of subtle forms of workplace
mistreatment (bullying and incivility) on Canadian nurses’ perceptions of patient safety risk and,
ultimately, nurse-assessed quality and prevalence of adverse events” (Laschinger, 2014, p. 284).
Level of evidence: Level IV- Single observational study
Study validity: Use your research text to guide you in determining bias in the following steps
of the research process (Polit and Beck pages 230-231.
Validity
analysis
criteria
Problem and purpose
statements
Mark an x
if very
serious
concerns
Your comments re major strengths and weaknesses
The problem in the study is the impact of bullying and
incivility on patient safety risk and nurse-assessed patient
outcomes.
The purpose of this study was “to investigate the impact
of subtle forms of workplace mistreatment on Canadian
nurses’ perceptions of patient safety risk and, ultimately
nurse-assessed quality and prevalence of adverse events”
(Laschinger, 2014, p. 284).
Theoretical base from
lit review and
conceptual framework
and concept
definitions
Concept of workplace bullying of Einarsen and
Mikkelsen
Design
Correlational
Ethical issues
No ethical issues
Sample and setting
 Inclusion and
exclusion
criteria
 Selection
method
Inclusion- Ontario hospital nurses on College of
Provincial registry list.
Exclusion- not on list
Construct of workplace incivility of Andersson and
Pearson
Random sample of Ontario hospital nurses
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY

(random
selection or
assignment,
convenience
Size of n
Measurement tools
64
Response rate of 52%
n= 641
*NAQ-R Negative Acts Questionnaire Revised
*Cortina’s Workplace Incivility Scale
*5-point Likert scale for perceptions of the effects of
negative interpersonal interactions in the workplace
*Sochalski Scale 0-4 rating nurses perceptions of the
frequency of common adverse patient outcomes over the
past year
*Aiken et al 1-4 rating the quality of care of their unit
Data collection
Questionnaire mailed out to participants
Responders:
88.7% women
60.7 baccalaureate prepared
69% full time
78.3% acute care
Procedures
Questionnaire mailed out initially then reminder letter
sent 3 weeks later then a replacement package sent out 1
month after reminder.
Data analysis
Used Statistical Package for Social Sciences.
Direct and Indirect effects of bullying and incivility on
quality of care and frequency of adverse events.
Used the approach of Baron and Kenny to test mediationthe extent to which an intervening variable influences the
impact of an independent variable on an outcome
variable.
Findings (discussion
of results) and
Interpretation of
findings : conclusions
of what is true ,
Bullying and all sources on incivility were significantly
related to nurse-assessed quality of care, adverse events,
and perceptions of patient safety risk.
Patient/family complaints were the individual adverse
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
implications of
conclusions
65
event most strongly related to bullying and physician and
coworker incivility.
Subtle forms of workplace mistreatment can have
detrimental effects on patient safety outcomes.
Recommendations
based on implications
Create environments that support professional nursing
practice that promote high-quality patient care and
establish positive patient safety cultures. Prevent negative
interpersonal interactions; establish zero tolerance
bullying/workplace incivility policies.
Presentation
Article in the Journal of Nursing Administration (JONA)
Credentials of the
researcher
Assessment of validity
of findings.
PhD, RN FAAN, FCAHS
The validity of the findings is sound. The studies
evaluating methods are measuring the concepts that they
are trying to measure.
Study Reliability: The reliability or accuracy and consistency of the study are reliable.
What are the results? What are the statistical answers to the research questions (statistical
significance)?
Descriptive statistics mean (SD)
Exposure to bullying experience was not high 1.45 (0.59)
Nurses reported relatively high quality of patient care on their units 3.34 (0.69)
Relatively few experiences of adverse events 2.03 (0.69)
Low workplace violence-related patient safety risk 2.31 (1.04)
Mediating Effects of Patient Safety Risk
Patient care quality and physician incivility B= -0.234, p< .05
Bullying and overall frequency of patient adverse events B= 0.241, p< .05
Physician incivility and overall frequency of patient adverse events B= 0.166, p< .05
Coworker incivility B= 0.148, p< .05
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
66
Workplace mistreatment related to patient safety risk
Bullying B= 0.328
Physician incivility B= 0.228
What is the clinical significance of the results? Patient safety is the clinical significance.
Applicability: Overall, the study suggests that workplace mistreatment can threaten patient
safety outcomes.
Overall Comments on validity and reliability: There are limitations to this study since crosssectional data was used and precludes attribution of cause and effect among the study variables.
The low questionnaire response rate and targeted sample limit generalizability and patient
outcomes were nurse-assessed not institutional data.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
67
Critical Appraisal of Quantitative Research form
Citation: Roche, M., Diers, D., Duffield, C., & Catling-Paull, C. (2010). Violence toward
nurses, the work environment and patient outcomes. The Journal of Nursing Scholarship, 42(1),
13-22. Doi: 10:1111/j.1547-5069.2009.01321.x
Study purpose or research questions: “To relate nurses’ self-rated perceptions of violence
(emotional abuse, threat, or actual violence) on medical-surgical units to the nursing working
environment and to patient outcomes,” (Roche, Diers, Duffield, & Catling-Paull, 2009).
Level of evidence: Single correlational/observational study-Level IV
Study validity: Use your research text to guide you in determining bias in the following steps
of the research process (Polit and Beck pages 230-231.
Validity
criteria
analysis Mark an x
if very
serious
concerns
Problem and purpose
statements
Theoretical base from
lit review and
conceptual framework
and concept
definitions
Design
Ethical issues
Sample and setting
 Inclusion and
exclusion
criteria
 Selection
method
(random
selection or
assignment,
convenience
 Size of n
Measurement tools
Your comments re major strengths and weaknesses
Problem-An unsafe working environment is detrimental
to nurses’ ability to deliver safe, quality care.
Purpose-Rate nurses’ perception of violence in medicalsurgical units and relate this to patient outcomes
Conceptual Framework
Cross sectional collection of data.
No ethical issued identified
94 randomly selected medical surgical wards in 21 public
hospitals across two states in Australia. ED’s, ICU’s,
Pediatrics, Obstetrics, and Psychiatric units were
excluded.
Random selection
All nurses on the floor were asked to complete survey
including clinical nurse specialists, registered nurses,
enrolled nurses, certified nursing assistants, and training
nurses were polled.
N=3099, overall response rate 80.3%
49 item Nursing Work Index-Revised
Environmental Complexity Scale
11 question nursing intervention questionnaire about
interventions that were delayed or not done.
Staffing matrix of the institutions
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Data collection
68
PRN-80 Patient acuity scale
Surveys were collected for seven consecutive days on
each unit from 2004-2006 and primary data were
collected by a trained nurse data collector.
RN=72.3
Procedures
Data analysis
Findings (discussion
of results) and
Interpretation of
findings : conclusions
of what is true ,
implications of
conclusions
Recommendations
based on implications
Presentation
Credentials of the
researcher
Assessment of validity
of findings.
Surveys were filled out for seven consecutive days on
each unit and were collected by trained nurse data
collectors with no affiliation to the hospital.
Data was collected from nurses and also by matrix and
census of the floor. Concurrent medical records were
also used.
Categorical variables were transformed to X per ward.
Continuous variables were calculated as a mean for the
ward.
Explanatory variables were added to statistical models in
sequence using a -2 log likelihood value. Poisson
regression models were used in the case of low event
counts of patient outcomes.
As ward environments becomes less stable (fewer RN’s,
increased workload, unanticipated changes in patient
status, perceived low nurse leadership, low nurse
autonomy, poor relationships with physicians, patients
awaiting placement) perceived violence increases. This
increases the poor patient outcomes related to patient
falls.
Use tools to identify violent patients. Encourage
reporting of incidents, management support strategies,
agencies must address disruptive behavior of any
employee or participating physician.
Journal of Nursing Scholarship
Michael Roche, RN, MHSc, CertMHN
Donna Diers, RN, PhD
Christine Duffield, RN, MHP, PhD
Christine Catling-Paull, RN, MSc, RM
The validity of the findings is sound. The study variables
adequately measure violence (actual and perceived)
toward nurses and the patient outcomes.
Study Reliability:
What are the results? What are the statistical answers to the research questions (statistical
significance)?
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
69
Correlation of Patient Adverse Events per Ward and Nurses Experiencing Violence
Falls
Med Errors
Delays in med admin
Physical Violence
0.21
0.22
0.15
Threat of Violence
0.19
0.22
0.10
The threat of physical violence along with actual physical violence is statistically relevant for
adverse patient outcomes. There is a positive correlation between the three outcomes and actual
physical violence. There was a positive correlation between threats of violence and medication
delays and falls.
Out of 947 nurses that reported emotional abuse, 14.7% stated that they had received emotional
abuse from a nursing co-worker and 9.8% polled that they had received emotional abuse from
more than one source.
What is the clinical significance of the results? If nurses have adequate resources and a full
staffing matrix, poor patient outcomes are decreased. Perceived violence will increase the
likelihood that nurses will seek employment elsewhere.
Applicability: The study is applicable to medical-surgical units exclusively. Further testing
would be needed to apply to all floors in the acute care setting. It is also polling violence that
was from patients directed at nurses not just nurse to nurse or physician to nurse violence.
Overall Comments on validity and reliability: The issue with validity and reliability is that the
study depends of the reporting of incidence which it states the nursing staff is not always filling
out the correct paperwork or they are reluctant to do so.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
70
Critical Appraisal of Quantitative Research form
Citation: Walrath, J. M., Dang, D., & Nyberg, D. (2013). An organizational assessment of
disruptive clinician behavior: Findings and implications. Journal of Nursing Care Quality, 28(2),
110-121. doi:10.1097/NCQ.0b013e318270d2ba
Study purpose or research questions: To understand the complexities of disruptive behavior
in a large academic medical center in order to 1) determine type, frequency and scope of
clinicians’ personal experience with disruptive behavior and impact on staff, patients, and the
organization 2) compare the disruptive behavior experiences of RNs and MDs, and 3) customize
interventions for RNs, MDs, interprofessional teams and the organization to foster culture
change and enhance patient safety.
Level of evidence: Single Correlational Study –Level IV
Study validity: Use your research text to guide you in determining bias in the following steps
of the research process (Polit and Beck pages 230-231.
Validity
analysis
criteria
Problem and purpose
statements
Mark an x
if very
serious
concerns
Your comments re major strengths and weaknesses
Problem: Disruptive behavior between clinicians is an
entrenched and intractable problem that undermines the
culture of safety for patients and clinicians.
The purpose of the study was to understand the
complexities of disruptive behavior in a large academic
medical center. The objectives were to 1) determine the
type, frequency, and scope of clinicians’ personal
experiences with disruptive behavior and impact on staff,
patients, and the organization; 2) compare disruptive
behavior experiences of RNs and MDs; 3) customize
interventions for RNs, MDs, interprofessional teams, and
the organization to foster culture change and enhance
patient safety.
Theoretical base from
lit review and
conceptual framework
and concept
definitions
Disruptive behavior is a multidimensional construct
demonstrated by numerous types of behaviors; current
literature presents a fragmented perspective of this
complex problem. In a previous qualitative study (See
Walrath, Dang, & Nyberg, 2010), the authors presented
Johns Hopkins Model for Disruptive Clinical Behavior to
increase clarity to the large literature base and improve
understanding on the topic. This model explains
disruptive behavior using 4 concepts: triggers, disruptive
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
71
behaviors, responses, and impacts. Disruptive behavior is
defined as “personal conduct, whether verbal or physical,
that negatively affects or potentially may affect patient
care including, but not limited to, conduct that interferes
with one’s ability to work with the other members of the
healthcare team.” The survey instrument subsequently
developed and used in this study was guided by this
conceptual model.
Design
Descriptive survey; an instrument Disruptive Clinician
Survey for Hospital Settings was developed to assess
disruptive behavior among healthcare professionals in the
hospital practice environment.
This study is in follow-up to a previous qualitative study
in which a conceptual model for disruptive behavior was
presented. (See Walrath, Dang, & Nyberg, 2010). The
design is an appropriate “next step” in researching this
subject.
Ethical issues
No ethical issues apparent or identified.
Sample and setting
 Inclusion and
exclusion
criteria
 Selection
method
(random
selection or
assignment,
convenience
 Size of n
Convenience sample. Total study population N = 5710
in one academic medical center. 3 clinician groups – all
levels of clinical and administrative RNs (n = 2759);
nurse practitioners, certified nurse midwives, certified
RN anesthetists, and physician assistance (n = 470); full
time School of Medicine clinical faculty, fellows, and
house staff MDs (n = 2481). Nurses and MDs in all
practice settings were included; agency RNS, RNs not
employed by the department of nursing and School of
Medicine clinical faculty and fellows currently not
practicing in the study hospital were excluded.
Response rate = 27.3%
Study was limited to RNs and MDs, and affiliates due to
funder’s restrictions.
Measurement tools
Disruptive Clinician Survey for Hospital Settings
Survey items included dichotomous, 4 and 5-point Likert
scales, and multiple choice patterns which were answered
based on their personal experiences “during the past
year”.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Data collection
72
The survey was available from October 11-November 1,
2010 on a secured Web-based system.
1559 clinician participants
35.8% (n = 987) RNs
20% (n = 496) MDs
16.2% (n = 76) affiliates
Most RNs and affiliates (89.3%) = female; most MDs
(60.9%) = male
Procedures
After IRB approval was obtained, an email was sent to
work addresses of study population inviting study
participation with a link to Web-based survey.
Completion of survey implied informed consent.
Participants could complete the survey at work or on
their own time. Three email reminders were sent during
the three week study period.
Data analysis
Descriptive, univariate, and bivariate analyses were
conducted using IBM SPSS 19. The Levine test for equal
variance was nonsignificant. Items with missing values
were deleted from the analyses.
Findings (discussion
of results) and
Interpretation of
findings : conclusions
of what is true ,
implications of
conclusions
84% of respondents reported personally experiencing
disruptive behavior during the past year. 73% of
respondents reported observing a coworker who was a
target of this behavior. RNs experienced a significantly
higher frequency of disruptive behaviors and triggers
than MDs; 45% of MDs and 37% of RNs reported that
their peer’s disruptive behavior affected them most
negatively. Disruptive behavior was reported more
frequently within the MD staff (45.1% in comparison to
36.5% among RN staff) and the affiliates reported MDs
as having the most negative impact. Most prominent
trigger for both MDs and RNs was organizational in
nature - pressure from high census, volume, and patient
flow. 189 incidences of patient harm related to disruptive
behavior were reported by study participants.
Recommendations
based on implications
Disruptive behavior is a complex phenomenon with
significant implications for staff, patients, and
organizations if not addressed. An organizational
assessment identifying the full scope of disruptive
behaviors is a first step to achieving and sustaining a
culture of trust, mutual respect, and collegiality which are
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
73
the hallmarks of a culture of safety. The Johns Hopkins
Model for Disruptive Clinician Behavior provides a
roadmap for such an assessment (see Walrath, Dang, &
Nyberg, 2010) and the survey provides actionable
information to address disruptive behavior as a systems
issue and can guide development of individual, team, and
organizational interventions.
Presentation
Article in the Journal of Nursing Care Quality
Credentials of the
researchers
Jo M. Walrath, PhD, RN
Deborah Dang, PhD, RN, NEA-BC
Dorothy Nyberg, MS, RN
Assessment of validity
of findings.
Reasonably sound validity of findings: see overall
comments below.
Study Reliability:
What are the results? What are the statistical answers to the research questions (statistical
significance)?
An independent-sample t test was performed to compare RNs’ and MDs’ means for each item in
the survey. (Affiliates were excluded from the analyses due to small sample size.)
RNs reported experiencing a significantly higher frequency of all disruptive behavior items than
MDs. The five highest rank-ordered means by role in the Disruptive Behavior subscale were:
RN
MD
n
mean (SD)
n
mean (SD)
P
Passive aggressive
731
3.03 (1.29)
342
2.65 (1.27)
<.001
Conflict
733
3.02 (1.11)
343
2.61 (1.14)
<.001
Malicious gossip
725
2.86 (1.28)
342
2.27 (1.14)
<.001
Self-centered
730
2.81 (1.21)
344
2.64 (1.23)
.03
Inappropriate use of 724
Communication tech.
2.72 (1.62)
344
2.01 (1.26)
<.001
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
74
RNs reported a higher frequency of occurrence for all triggers of disruptive behavior. All
subscale items were significant for RNs compared with MDs, except for the item lack of
competency. The 5 highest rank-ordered means by role for the Trigger subscale were:
Pressure from high 727
census, volume, and
patient flow
3.32 (1.24)
339
2.81 (1.37)
<.001
Environmental over- 725
load
3.21 (1.37)
338
2.54 (1.38)
<.001
Chronic, unresolved 722
system issues
3.14 (1.29)
338
2.71 (1.35)
<.001
Personal characteristics
720
2.92 (1.21)
336
2.66 (1.19)
.001
Unit/org. culture
724
2.90 (1.34)
340
2.62 (1.36)
.001
What is the clinical significance of the results? Disruptive behavior is an organizational
problem which undermines a culture of safety. A major finding of this study is that participants
reported direct knowledge of actual harm (rather than the perception of harm) to patients as a
result of disruptive behavior. Of the 186 reported incidents of harm, 77.2% were rated as
temporary (requiring treatment or intervention, or prolonged hospitalization), 10% permanent
(wrong procedure or wrong site surgery), and 12.7% requiring life-sustaining interventions
(intubation or emergency surgery).
Applicability: Similar hierarchical structures and common processes are inherent in all hospital
organizations which would allow for generalization outside an academic medical center settings,
implying significant potential impact for patients in America as well as globally.
Overall Comments on validity and reliability:
Based on the rigor of survey instrument development and findings, we can infer reasonable
validity and reliability with the following caveats:
Due to the perception that the connotations of the term disruptive behavior may predispose how
respondents answered, the survey instrument has since been retitled to the more neutral phrasing
Survey of Unprofessional Behaviors: Triggers, Responses, Impacts.
The findings in this study indicated that clinicians speak up and do not let disruptive behavior get
in the way of patient care, an alteration from previous research findings which demonstrated
intimidation is a barrier to reporting. However, because of the sensitivity of this item, the authors
acknowledge the possibility that participants sacrificed the accuracy of their responses in favor
of one that would be perceived as more socially acceptable.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
75
A response rate of 27.3%, lack of data on non-responders, and potential that responders were
victims of disruptive behavior raise into question possible selection bias and representativeness
of the results. Survey length and specificity of demographic questions may have contributed to
overall response rate and subscale variability due to fatigue while responding and fear of being
identified; the survey has since been shortened and specificity of demographic items has been
decreased.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
76
Critical Appraisal of Quantitative Research form
Citation: Wilson, B.L. & Phelps, C. (2013). Horizontal hostility: A threat to patient safety.
JONA’S Healthcare Law, Ethics, and Regulation, 15(1), 51-57.
doi:10.1097/NHL0b013e3182861503
Study purpose or research questions: “The purpose of this study was to survey registered nurses
at a 220-bed community hospital in the Southwest to determine to degree of perceived hostility
in the workplace, and (if present) to determine to extent that horizontal hostility behaviors from
either RN-to-RN or physician-to-RN influenced nurse behaviors directly related to patient care,”
(Wilson &Phelps, 2013).
Level of evidence: Single observational study Level IV
Study validity: Use your research text to guide you in determining bias in the following steps
of the research process (Polit and Beck pages 230-231.
Validity
criteria
analysis Mark an x
if very
serious
concerns
Problem and purpose
statements
Theoretical base from
lit review and
conceptual framework
and concept
definitions
Design
Ethical issues
Sample and setting
 Inclusion and
exclusion
criteria
 Selection
method
Your comments re major strengths and weaknesses
Problem: Healthcare workers that feel intimidated or
bullied are less likely to speak out when they see an error
in patient care and are more likely to take part in
“workarounds” in order to not deal with bullying
individuals.
Purpose:
1) To determine the degree of perceived hostility in a 220
bed hospital.
2) To determine to degree of RN-to-RN and physician-toRN hostility
3) Determine how this influences nurse’s behaviors
directly related to patient care.
The study was modeled on previous studies from the
American Association of Critical Care Nurses, “ Lateral
Violence in Nursing” and “Seven Crucial Conversations
in Healthcare.”
Cross sectional survey
No ethical issued identified
Surveys were given to all five hundred nurses working in
a 220-bed hospital during a 2 month period.
Exclusions: Registry and travel nurses
N=500
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
(random
selection or
assignment,
convenience
 Size of n
Measurement tools
Response rate was 26%
Ordered and dichotomous 28 question survey based on a
survey in a previous study titled “Lateral Violence in
Nursing Survey.”
Surveys were given to all who met inclusion criteria.
The surveys were to be filled out and returned to locked
boxes.
Data collection
Procedures
Data analysis
Findings (discussion
of results) and
Interpretation of
findings : conclusions
of what is true ,
implications of
conclusions
Recommendations
based on implications
77
x
Respondents:
 10 years of experience= 58%
 baccalaureate degree=58%
 female = 90%
 30-39 years old= 23.3%
 40-49 years old= 35.3%
 50 and older= 31.5%
Surveys were handed out and nurses were asked to return
the surveys in a sealed enveloped in high traffic areas as
to protect anonymity such as near time clocks or in
highly frequented hallways. Surveys were collected twice
weekly and reviewed and kept in a locked filing cabinet.
They were reviewed and transcribed by a nurse
researcher with no affiliation to the hospital and no
knowledge of the unit locations.
Univariate analysis was performed. No discussion of
Levine’s test.
60% (n=78) of respondents had witnessed horizontal
hostility in the last month of working. The top answer
for who was giver of the horizontal hostility was “a nurse
from my unit.” (n=66) followed by a physician (n=53).
Of those who answered this question 58% (n=60) stated
they spoke with a peer about this problem. 17.3% (n=18)
stated they spoke directly to a manager. The top reason
people chose to ignore the horizontal hostility was that it
would make the situation worse.
1) Educate staff nurses about horizontal hostility and why
it exists.
2) Examine your own leadership style
3) set behavior standards and keep employees
accountable to them
4) Provide ongoing training to managers and charge
nurses
5) Provide nurses with skills to be able to address conflict
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Presentation
Credentials of the
researcher
Assessment of validity
of findings.
78
with peers like conflict management training and
assertiveness
6) Give new nurses a shield (provide coaching about
deflecting)
7) Give new nurses a chance to bond with one another
8) Offer 2 way feedback for new nurses and their
preceptors
9) Practice self-evaluation
Article in JONA’S Healthcare Law, Ethics, and
Regulation
Barbara L. Wilson, PhD, RNC-OB
Connie Phelps, MSN, RNC-OB
The validity is sound. The study measures what they
have set out to measure which is horizontal hostility
among nurses.
Study Reliability:
What are the results? What are the statistical answers to the research questions (statistical
significance)?
60% of respondents stated they had seen horizontal hostility in the last month. Of those who had
witnessed it, 61% stated it came from a nurse from their own department, 49.5 stated that it came
from a physician, 27.1% stated that it came from a charge nurse, and 24.3 stated that it came
from an employee from an unspecified department.
When asked who they spoke about it with, 57.3% stated they spoke with a co-worker about the
incident, while 32.7 stated they did not speak with anyone. 17.3 percent did not speak with
anyone.
If they did not confront the person, 73.8 % stated it was because they felt it would make the
situation worse. The following actions did occur because of horizontal hostility: I have muddled
through patient procedures that I felt unsure about, I have used a piece of medical equipment I
am unfamiliar with because I did not want to ask for help, I have lifted or ambulated a person
that was two assist by myself, I have given medication without getting a physician clarification
order, I have interpreted an unreadable error instead of calling for clarification, I have held
medication and waited to the next shift to ask questions and verify, and I have carried out an
order that I did not feel was in the best interest of my patient but did not clarify it. These results
were choosing all that apply.
What is the clinical significance of the results? The clinical significance of this study is that it
will allow hospitals to see how horizontal hostility is making nurses seek other employment and
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
79
therefore losing staff and costing their facilities money. They may also see that it is a factor in
nurses leaving the profession.
Applicability: It is applicable to hospitals only. Further studies would need to be done in order
assess other areas of horizontal hostility in healthcare that are not in an acute care setting.
Studies would have to be repeated in other hospitals of differing sizes and populations.
Overall Comments on validity and reliability:
The overall validity and reliability was sound. There are still many unanswered questions since
many nurses chose to fill out the survey with the option, “I choose not to answer this question.”
The results would be more relevant if the data had been more focused without this option for
people filling out the survey to choose.
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Appendix C
Matrix
80
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
81
MATRIX TABLES FOR
A QUALITATIVE OR QUANTITATIVE ARTICLE
Article, Level
of Evidence,
PICO(T)
Chipps, E.,
Stelmaschuk,
S., Albert, N.
M., Bernhard,
L., &
Holloman, C.
(2013).
Workplace
bullying in the
OR: Results of
a descriptive
study. AORN
Journal, 98(5),
479-493.
http://dx.doi.org
/10.1016/j.aorn.
2013.08.015
Purpose,
Framework,
Design
The study sought
to describe the
incidence of
workplace
bullying among
perioperative
RNs, surgical
technologists, and
unlicensed
perioperative
personnel at two
academic medical
centers and
determine (a)
whether the
demographic
variables of
gender, ethnicity,
Level VIhospital, years of
Descriptive
experience on the
Study
unit, years in the
profession, and
In the
job title predict
perioperative
the experience of
setting, what is workplace
the prevalence
bullying, (b)
and what are the whether a
predictors of
relationship exists
workplace
between
bullying, and is workplace
there a
bullying and
relationship
emotional
between
exhaustion, and
bullying
(c) whether
behavior and
bullying is
emotional
associated with
exhaustion, and perceptions of
bullying
patient safety in
behavior and
the operating
perceptions of
room (OR).
Measurement
Tools
Sample &
Size
Results of
Research
Comments
Negative Acts
QuestionnaireRevised (NAQR)- 22 items.
Cronbach alpha
scores ranging
from 0.81 to
0.92
The sample
included
registered
nurses,
surgical
techs, and
unlicensed
personnel
working in
the operating
room at two
academic
Magnet
status
hospitals.
The study found
that
approximately
one-third of
participants
indicated being
targets of
workplace
bullying; 59%
had witnessed
coworkers being
bullied.
Perpetrators of
bullying are
broken down as
follows: Other
employees on
unit 56%,
RNs on their unit
56%,
Physicians 44%,
RN managers
33%,
and Charge RNs
11%. A
significant
moderate,
positive
correlation
among bullying
frequency (rho
.56, P < .001),
bullying
intensity (rho
.54, P < .001),
and emotional
exhaustion
exists. There is a
moderate,
negative
The study results
provide
meaningful
information in
helping to answer
the PICO(T)
question posed by
the authors. The
eight negative
acts that were
associated with
perceived
compromises in
patient safety
support an
association
between
behaviors that
undermine a
culture of safety
in the workplace
and a perception
that patient safety
outcomes are
negatively
affected. There
were no statistics
in the study that
reflect what
patient safety
outcomes are
affected, but there
is simply a
perception that
they are being
affected. The
study does not
distinguish
whether the
patients receiving
*Nine item
Emotional
Exhaustion
Subscale of the
Maslach
Burnout
Inventory
(MBI) Seven
point Likert
scale 0-6, never
to daily, scores
split and coded
into 0-16-low,
17-26moderate, 27 or
more-high.
Cronbach alpha
score 0.91.
*23 additional
questions
including eight
demographic
questions, eight
questions
related to
bullying
experiences and
witnessing
bullying
behaviors at
(N = 167).
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
patient safety?
This study used a
model of bullying
from Hutchinson
et al. In this
model,
“organizational
antecedents” must
be present for
bullying to exist
in the work
environment.
Design used was
a cross-sectional
survey
work, and seven
questions about
the effect of
bullying on near
errors, errors,
expectations,
and safety of
patients.
Nurse experts,
clinical nurse
specialists,
nurse
administrators,
and staff nurses
reviewed
questions for
clarity.
82
correlation
surgical services
among bullying
are inpatient or
frequency (rho
outpatient. The
e.31, P < .001),
evidence is a
bullying
Level VIintensity (rho
Descriptive study.
.29; P < .001),
It is useful in
and job
providing
satisfaction. 3%
information
indicated that
regarding
bullying affected
operating room
errors and
culture which can
perceptions of
impact
patient
hospitalized
satisfaction. 6%
patients. Due to
indicated that
the single nature
bullying affected
of the study, it
patient safety.
cannot be
Eight negative
generalized to a
acts were
larger or different
associated with
population such
perceived
as acute care
compromises in
patients and
patient safety
further research is
outcomes;
warranted in
impossible
order to
deadlines (odds
generalize these
ratio 2.4 [95%
particular
CI, 1.4-4.0]),
research findings.
having opinions
ignored (odds
ratio 2.3 [95%
CI, 1.4-3.7]),
having false
allegations made
(odds ratio 2.0
[95% CI 1.23.3]), excessive
monitoring of
work (odds ratio
2.0 [95% CI,
1.2-3.1]), hints
from others that
the respondent
should quit his or
her job (odds
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
83
ratio 1.9, [95%
CI, 1.0-3.5]),
being reminded
of errors or
mistakes (odds
ratio 1.8 [95%
CI, 1.1-3.0]),
being humiliated
at work (odds
ratio 1.8 [95%
CI, 1.1-3.0]), and
being the target
of practical jokes
(odds ratio 1.7
[95% CI, 1.12.8]).
Flynn, L.,
Liang, Y.,
Dickson, G. L.,
Xie, M., & Suh,
D. (2012).
Nurses' practice
environments,
error
interception
practices, and
inpatient
medication
errors. Journal
of Nursing
Scholarship, 44
(2), 180-186.
doi:10.1111/j.1
5475069.2012.0144
3.x
To determine the
relationships
among
characteristics of
the nursing
practice
environment,
nurse staffing
levels, nurses’
error interception
practices, and rate
of nonintercepted
medication errors
in acute care
hospitals.
Reason’s error
theory
The Nursing
Organization and
Level IV- single Outcomes Modelobservational
link between the
study
presence of
characteristics in
Is there a
the environment
relationship
that support
between
professional
characteristics
nursing practice
PES-NWI- 30
items of the
Practice
Environment
Scale of the
Nursing Work
Index-Construct
validity and
reliability
proven through
previous and
current studies.
Four item scale
of interception
practices
Validity and
reliability is
inferred based
on rigor of
study methods.
Appraisal tool
indicated
reasonable
validity and
reliability.
Survey
participants
were
registered
nurses
employed in
a position of
staff nurse on
their unit.
Exclusionfloat staff not
included. N
= 686. Mean
response rate
was 96%.
A supportive
practice
environment was
positively
correlated with
error interception
practices among
nurses in the
sample of
medical-surgical
units. Nurse
interception
practices were
inversely
associated with
medication error
rates. Nurses’
interception
practices
[(−0.19, 0.08,
73.98, −2.48,
.015)]. Nursing
practice
environment
[(−0.26, 0.30,
79.95, −0.87,
.388)].
The study
addresses the
issue that if there
is a positive,
supportive work
environment,
medication errors
are decreased.
This does pertain
to the PICO(T)
question posed in
this research. It
does not further
address how
medication
interception and
errors are affected
by a work
environment in
which behaviors
that undermine a
culture of patient
safety are present.
A significant
feature of this
study is it
measures actual
patient safety
instead of
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
of the nursing
practice
environment,
nurse staffing
levels, and
nurses’ error
interception
practices, and
rate of
nonintercepted
medication
errors in acute
care hospitals?
and positive
patient outcomes.
Laschinger, H.
K. (2014).
Impact of
workplace
mistreatment on
patient safety
risk and nurseassessed patient
outcomes. Jour
nal of Nursing
Administration,
44(5), 284-290.
doi:10.1097/NN
A.00000000000
00068
The purpose of
this study was “to
investigate the
impact of subtle
forms of
workplace
mistreatment on
Canadian nurses’
perceptions of
patient safety risk
and, ultimately
nurse-assessed
quality and
prevalence of
adverse events”
(Laschinger,
2014, p. 284).
Level IVSingle
observational
study
Does the
presence of
subtle
workplace
bullying and
incivility affect
nurse
perceptions of
patient safety?
84
perceived patient
safety as in other
studies
Limitations of
using incident
reports for data
collection and the
well documented
underreporting of
medication errors
or near misses
The study design
is single
observational.
Concept of
workplace
bullying of
Einarsen and
Mikkelsen,
Construct of
workplace
incivility of
Andersson and
Pearson
Study DesignCorrelational
NAQ-R
Negative Acts
Questionnaire
Revised,
Cortina’s
Workplace
Incivility Scale,
5-point Likert
scale for
perceptions of
the effects of
negative
interpersonal
interactions in
the workplace,
Sochalski Scale
0-4 rating
nurses
perceptions of
the frequency of
common
adverse patient
outcomes over
the past year,
Aiken et al 1-4
rating the
quality of care
of their unit.
Cronbach’s a
reliability was
noted to be
InclusionOntario
hospital
nurses on
College of
Provincial
registry list.
Sample size
is 641 with a
response rate
of 52%.
Responders
were 88.7%
women,
60.7
baccalaureate
prepared,
69% full
time, and
78.3% acute
care.
Bullying and all
sources on
incivility were
significantly
related to nurseassessed quality
of care, adverse
events, and
perceptions of
patient safety
risk.
Patient/family
complaints were
the individual
adverse event
most strongly
related to
bullying and
physician and
coworker
incivility. Nurse
assessed patient
safety risks are
as follows;
Patient care
quality and
physician
incivility (B= 0.234, p< .05),
Bullying and
overall
frequency of
The data supports
a positive
correlation
between
behaviors that
undermine a
culture of safety
and adverse
patient safety
events. The
events in this
study are
measured by
nurse assessment
and not by
number of
occurrences.
Adverse events
are not broken
down into
categories but
instead labeled
patient adverse
events and patient
care quality. This
particular study
shows that there
is a stronger
positive
correlation
between bullying
and patient
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
excellent for the
Negative Acts
Questionnaire,
noted as .89 and
.81 for
Cortina’s, and
reliability/validi
ty statements
are made
regarding
Sochalski’s and
Aiken’s tools,
and more softly
for the items
related to
patient safety
risk.
Roche, M.,
Purpose-Rate
Diers, D.,
nurses’
Duffield, C., &
perception of
Catling-Paull,
violence in
C. (2010).
medical-surgical
Violence toward
units and relate
nurses, the work
this to patient
environment
outcomes.
and patient
outcomes. The The conceptual
Journal of
framework
49 item Nursing
Work IndexRevised
Environmental
Complexity
Scale
11 question
nursing
intervention
questionnaire
about
94 randomly
selected
medical
surgical
wards in 21
public
hospitals
across two
states in
Australia.
ED’s, ICU’s,
85
patient adverse
adverse events
events (B=
than physician
0.241, p< .05),
incivility or coPhysician
worker incivility
incivility and
and patient
overall
adverse events.
frequency of
There are
patient adverse
limitations to this
events (B=
study since cross0.166, p< .05),
sectional data was
Coworker
used and
incivility (B=
precludes
0.148, p< .05).
attribution of
Workplace
cause and effect
mistreatment as
among the study
related to patient
variables. The
safety is as
low questionnaire
follows;
response rate and
Bullying B=
targeted sample
0.328), Physician
limit
incivility B=
generalizability
0.228.
and patient
outcomes were
nurse-assessed
not institutional
data. This is
applicable to the
authors’ PICO(T)
question as it
shows a positive
correlation
between bullying
and incivility and
adverse patient
outcomes.
As ward
The study results
environments
are relevant in
becomes less
helping to answer
stable (fewer
the PICO(T)
RN’s, increased
question. The
workload,
study shows a
unanticipated
positive
changes in
correlation
patient status,
between various
perceived low
forms of
nurse leadership,
workplace
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Nursing
Scholarship,
42(1), 13-22.
Doi:
10:1111/j.15475069.2009.0132
1.x
Single
correlational/ob
servational
study-Level IV
How do nurses’
self-rated
perceptions of
violence
(emotional
abuse, threat, or
actual violence)
on medicalsurgical units
affect the
nursing working
environment
and patient
outcomes.
included concepts
of nursing
resources,
workload, the
working
environment and
patient outcomes
without
predictions of
specific links.
Design- Cross
sectional
collection of data
by surveys and
primary
collection of unit
data for 1 week
periods
interventions
that were
delayed or not
done.
Staffing matrix
of the
institutions
PRN-80 Patient
acuity scale
Correlation
analysis was
conducted and
P values were
given. EN,
enrolled nurse,
registered
nurse,
autonomy,
nurse-doctor
relations,
leadership,
environmental
complexity,
unanticipated
changes in
acuity, nursing
hours of care
required per
patient/nurse
hours per
patient day:
p<.05.
Pediatrics,
Obstetrics,
and
Psychiatric
units were
excluded.
Random
selection
used. All
nurses on the
floor were
asked to
complete
survey
including
clinical nurse
specialists,
registered
nurses,
enrolled
nurses,
certified
nursing
assistants,
and training
nurses were
polled.
Target
sample was
3,099 nurses
with an
80.3%
response
rate. (N =
2,487) RN’s
made up
72.3% of
respondents.
86
low nurse
autonomy, poor
relationships
with physicians,
patients awaiting
placement),
perceived
violence
increases.
Correlation of
Patient Adverse
Events per Ward
and Nurses
Experiencing
Physical
Violence and
Threat of
Violence; Patient
falls (0.21, 0.19),
Medication
errors (0.22,
0.22), Delays in
medication
administration
(0.15, 0.10).
Out of 947
nurses that
reported
emotional abuse,
14.7% stated that
they had
received
emotional abuse
from a nursing
co-worker and
9.8% polled that
they had
received
emotional abuse
from more than
one source.
violence and
threats of
violence, and
adverse patient
safety events. The
physical and
threat of violence
in this article is
nurse perceived
but the actual
patient safety
outcomes are
measured by
occurrence
through primary
data collection.
The study was
limited by selfreporting of
violence and
assessment of
tasks not done or
delayed. Unitlevel primary data
collection was
limited by a 7-day
collection period
which may have
resulted in
missing some
instances of falls
or medication
errors. Patient
adverse outcome
rates were very
low which limited
statistical power.
Study results lend
emphasis
regarding a
positive
correlation
between
behaviors that
undermine a
culture of safety
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
Walrath, J. M.,
Dang, D., &
Nyberg, D.
(2013). An
organizational
assessment of
disruptive
clinician
behavior:
Findings and
implications.
Journal of
Nursing Care
Quality, 28(2),
110-121.
doi:10.1097/NC
Q.0b013e31827
0d2ba
Single
Correlational
Study –Level
IV
How does
disruptive
behavior in a
large academic
medical center
affect (a) type,
frequency and
scope of
clinicians’
personal
experience with
disruptive
behavior and
what impact
does it have on
staff, patients,
and the
organization (b)
The purpose of
the study was to
understand the
complexities of
disruptive
behavior in a
large academic
medical center.
The objectives
were to (a)
determine the
type, frequency,
and scope of
clinicians’
personal
experiences with
disruptive
behavior and
impact on staff,
patients, and the
organization; (b)
compare
disruptive
behavior
experiences of
RNs and MDs;
(c) customize
interventions for
RNs, MDs,
interprofessional
teams, and the
organization to
foster culture
change and
enhance patient
safety.
Johns Hopkins
Model for
Disruptive
Clinical
Behavior, This
Disruptive
Clinician
Survey for
Hospital
Settings:
Survey items
included
dichotomous, 4
and 5-point
Likert scales,
and multiple
choice patterns
which were
answered based
on their
personal
experiences
“during the past
year”.
Total study
population:
Clinicians in
one urban
academic
medical
center in the
mid-Atlantic
region of the
United States
(N = 5710).
Three
clinician
groups: (a)
all levels of
clinical and
administrativ
e RNs (n =
2759); (b)
nurse
practitioners,
certified
nurse
midwives,
certified RN
anesthetists,
and
physician
assistants (n
= 470); (c)
full time
School of
Medicine
clinical
faculty,
fellows, and
house staff
MDs (n =
2481).
Nurses and
MDs in all
practice
87
and adverse
patient outcomes
in acute care
settings.
84% of
The study results
respondents
will help answer
reported
the PICO(T)
personally
question under
experiencing
investigation.
disruptive
This study
behavior during
continues to show
the past year.
a positive
73% of
correlation
respondents
between
reported
disruptive
observing a
behaviors and
coworker who
adverse patient
was a target of
outcomes. This
this behavior.
particular study
RNs experienced
shows that
a significantly
disruptive
higher frequency
behavior is
of disruptive
prompted by
behaviors and
organizational
triggers than
triggers that can
MDs; 45% of
then lead to
MDs and 37% of
negative patient
RNs reported
outcomes. These
that their peer’s
results are
disruptive
mirrored in the
behavior affected
Roche, Diers,
them most
Duffield, &
negatively.
Catling-Paull,
Disruptive
(2010) article
behavior was
which indicates
reported more
that perceptions
frequently within of violence were
the MD staff
related to adverse
(45.1% in
patient outcomes
comparison to
through unstable
36.5% among
or negative
RN staff) and the
qualities of the
affiliates
work
reported MDs as environment. The
having the most
sample size is
negative impact.
comparatively
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
what are the
disruptive
behavior
experiences of
RNs and MDs,
and (c) what
interventions
are there for
RNs, MDs,
interprofessiona
l teams and the
organization to
foster culture
change and
enhance patient
safety.
model explains
disruptive
behavior using 4
concepts: triggers,
disruptive
behaviors,
responses, and
impacts.
Disruptive
behavior is
defined as
“personal
conduct, whether
verbal or
physical, that
negatively affects
or potentially may
affect patient care
including, but not
limited to,
conduct that
interferes with
one’s ability to
work with the
other members of
the healthcare
team.” The
survey instrument
subsequently
developed and
used in this study
was guided by
this conceptual
model.
DesignDescriptive
survey-Follow up
to previous study.
settings were
included.
Response
rate = 27.3%.
(N = 1559);
35.8% (n =
987) RNs;
20% (n =
496) MDs;
16.2% (n =
76) affiliates.
Most RNs
and affiliates
(89.3%) =
female; most
MDs
(60.9%) =
male.
88
Most prominent
large in this study
trigger for both
although a
MDs and RNs
response rate of
was
27.3%, lack of
organizational in
data on nonnature - pressure
responders, and
from high
potential that
census, volume,
responders were
and patient flow.
victims of
189 incidences
disruptive
of patient harm
behavior raise
related to
into question
disruptive
possible selection
behavior were
bias and
reported by
representativeness
study
of the results.
participants. Of
Generalizability
the 189 reported
is limited due to
incidents of
one study setting
harm, 77.2%
but similar
were rated as
structures and
temporary
processes in most
(requiring
hospitals allows
treatment or
consideration for
intervention, or
applicability in
prolonged
other than
hospitalization), academic hospital
10% permanent
settings. There is
(wrong
no further
procedure or
narrowing of the
wrong site
categories.
surgery), and
12.7% requiring
life-sustaining
interventions
(intubation or
emergency
surgery).
Contrary to
previous findings
that indicate
intimidation is a
barrier to
reporting, this
study indicated
that clinicians
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
89
speak-up and do
not let disruptive
behavior get in
the way of
patient care or
reporting of
deterioration; the
authors
acknowledge the
possibility that
due to the
sensitivity of this
item, participants
sacrificed the
accuracy of their
responses in
favor of one that
would be
perceived as
more socially
acceptable.
Wilson, B.L. &
Phelps, C.
(2013).
Horizontal
hostility: A
threat to patient
safety. JONA’S
Healthcare
Law, Ethics,
and Regulation,
15(1), 51-57.
doi:10.1097/NH
L0b013e318286
1503
Single
observational
study Level IV
In a 220-bed
community
hospital in the
Southwest,
what is the
Purpose:
The purpose of
this study is: (a)
determine the
degree of
perceived
hostility in a 220
bed hospital;
(b) determine the
degree of RN-toRN and
physician-to-RN
hostility; (c)
determine how
perceived
hostility
influences nurse’s
behaviors directly
related to patient
care.
Design- Cross
sectional survey
Ordered and
dichotomous 28
item survey to
determine the
level of
perceived
horizontal
hostility (HH)
in an acute care
Magnetaspiring
hospital and
nurse actions as
a result of that
experience.
The survey was
modeled on
contents is a
previous study
from the
American
Association of
Critical Care
entitled “Seven
Surveys were
given to all
five hundred
nurses
working in a
220-bed
hospital
during a 2
month
period;
response rate
was 26% (N
= 130).
Respondents
were as
follows:
10 years’
experience=
58%,
baccalaureate
degree=
58%,
female =
90%, 30-39
60% (n=78) of
respondents
reported
observing HH at
least monthly,
with the majority
of respondents
reporting they
witnessed hostile
behaviors
weekly. The top
answer regarding
the category of
coworker
observed
exhibiting HH
toward another
person was “a
nurse from my
unit” (n=66),
followed by a
physician
(n=53). Of those
who answered
The research for
this article shows
that nurses
experience
horizontal
violence in the
workplace (60%).
The article
addresses nurse
care behaviors
that result
because of
horizontal
violence that
could contribute
to adverse patient
outcomes.
Numbers of
behaviors
potentially
compromising
patient safety are
not provided;
options had a
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
degree of
perceived
hostility in the
workplace, and
(if present) to
what to extent
that horizontal
hostility
behaviors from
either RN-toRN or
physician-toRN influenced
nurse behaviors
directly related
to patient care?
Crucial
Conversations
in Healthcare”
and the survey
by Stanley et al.
entitled “Lateral
Violence in
Nursing
Survey”.
years old=
23.3%, 40-49
years old=
35.3%
50 and
older=
31.5%.
90
this question,
58% (n=60)
stated they spoke
with a peer or
coworker about
perceived HH;
17.3% (n=18)
stated they had
addressed the
perpetrator
directly to fully
express their
concerns. The
most common
reason people
gave as the
reason for failure
to confront
horizontal
hostility was that
it would make
their work
situation worse,
followed by fear
of retaliation.
Respondents
reported the
following actions
because of
horizontal
hostility:
I have muddled
through patient
procedures that I
felt unsure about,
I have used a
piece of medical
equipment I am
unfamiliar with
because I did not
want to ask for
help, I have
lifted or
ambulated a
person that was
two assist by
“select all that
apply” instruction
on the
questionnaire.
The sample size
is relatively
small. This article
supports the
PICO(T) question
under study as it
shows how HH
can potentially
lead to adverse
patient events
through the effect
on nurse care
behaviors.
A major
limitation to this
study was the
number of
respondents who
selected the
“choose not to
answer” option
for several of the
study variables
which
significantly
limited the kinds
of analysis that
could be done.
For example,
because many
nurses did not
want to identify
their unit, adverse
events by unit in
relation to levels
of perceived
hostility could not
be examined due
to insufficient
statistical power.
Asking for home
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
91
myself, I have
given medication
without getting a
physician
clarification
order, I have
interpreted an
unreadable error
instead of calling
for clarification,
I have held
medication and
waited to the
next shift to ask
questions and
verify, and I
have carried out
an order that I
did not feel was
in the best
interest of my
patient but did
not clarify it.
unit identification
points to a
potential study
design flaw which
should be
considered in
future research
efforts.
Comments
QUALITATIVE
Article, Level
of Evidence,
PICO(T)
Purpose,
Framework,
Design
Walrath, J. M.,
The purpose of
Dang, D., &
the study was to
Nyberg, D
conduct focus
(2010). Hospital groups with RNs
RNs’
to gain an
experiences
understanding of
with disruptive how RNs describe
behavior: A
disruptive
qualitative
clinician behavior
study. Journal
and its impact
of Nursing Care
based their
Quality, 25(2),
observed and
105-116.
actual
doi:10.1097/NC
experiences on
Q.0b013e3181c the front lines of
Data
Collection and
Analyzing
Sample &
Size
Results of
Research
IRB approval
and oral consent
from
participants
obtained. A
clinical
psychologist
external to the
organization
facilitated 90minute focus
group sessions,
using semi
structured
interview
Purposive
convenience
sampling of
96 RNs in an
acute care
hospital
within an
academic
medical
center
located in the
Northeastern
United
States. The
recruitment
Participants
reported the
occurrence of
disruptive
behaviors in all
practice settings
and between
/among a wide
variety of
healthcare
personnel. 168
different
disruptive
behaviors were
identified and
This article assists
with answering the
PICO(T) question
under examination.
It further
categorizes the
disruptive behavior
experienced in the
workplace. While
there is no further
information in the
study that addresses
patient specific
outcomes, the study
highlights nurses’
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
7b58e
Single
Qualitative
Study-Level VI
What are RNs’
perceptions
regarding the
characteristics
of clinician
disruptive
behavior and
what is the
perceived
impact based on
their observed
and actual
experiences in a
patient care
setting?
patient care
delivery.
questions based
on the
conceptual
Disruptive
framework.
behavior is a
Focus group
complex
size was from 7
construct and full to 14 RNs.
understanding
Pseudo names
requires
were used when
examination of
describing
causes, individual individuals
responses, effects involved in
on individuals
disruptive
and organizations, behavior events
and perceptions
to ensure
of harm to
confidentiality
patients. Because of sensitive
the researchers
information.
found no
The sessions
conceptual
were audioframework that
recorded and
included these
held between
interrelated
January and
concepts in a
March 2008.
meaningful way,
The recorded
the researchers
sessions were
adapted Pearson
recorded
and colleagues’
verbatim and
framework on
validated for
workplace
accuracy
incivility and
against the
developed a
original
framework for
recordings.
organizing and
Nudist6
describing
software
disruptive
program
behavior, which
designed for
included 4
narrative
primary concepts: analysis was
triggers,
used to manage
disruptive
the interview
behaviors,
data and
responses, and
facilitate the
impacts.
coding process.
Design:
Deductive and
Descriptive
inductive
process
invited
participation
through
information
of the study
distributed
across the
Department
of Nursing
via posters,
internal Web
sites, and
individual
letters to
RNs (N =
2467). 32.3%
of
participants
were nurse
managers
and shift
coordinators;
52% were
staff nurses;
15.6% were
advanced
practice
nurses. 95%
of
participants
were female.
70.8% were
white; 12.5%
were Asian;
9% were
black; 3.1%
were
Hispanic/Lati
no
92
then synthesized
into 21
categories.
Within these
categories, 3
themes emerged:
incivility,
psychological
aggression, and
violence. The 10
most frequently
identified
categories within
these themes
were
rude/disrespectfu
l (= Incivility);
engaging in
gossip,
intimidation/thre
ats, passive
aggressive
behavior, refusal
to do one’s job,
verbal
aggression,
power play,
condescending
language/dress
down,
professional
disregard ( =
psychological
aggression); and
physical violence
(= violence). Out
of the personal
experiences
reported, 225
disruptive
behavior events
were coded.
Physicians were
identified as
instigators in
42% of events;
perceptions that
patient safety is
potentially
compromised by
disruptive behavior.
The study would
increase in evidence
level if the
responses were
measured using
quantitative
methods and be
more universal if a
larger sample size
was used,
presenting
opportunities in
future studies. The
information
obtained from this
research article
mimics (corrected
spelling) or you can
say “is in alignment
with information
found in other…”
the information
found in other
articles that indicate
lateral violence is
experienced by a
majority of
healthcare workers
and has a potentially
negative impact on
patient outcomes. A
3.9% response rate
and the potential
that participants
were victims of
disruptive behavior
and were ready to
share their
experiences raises
the possibility of
selection bias and
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY
qualitative study
– no specified
tradition
processes were
used to ode the
data. Two
members of the
research team
independently
assigned codes
to text segments
of the
transcribed
interviews.
After reaching
consensus on
the codes
through
comparison and
discussion, the
full research
team was
convened to
review, identify
patterns, and
synthesize the
initial codes
into broader
categories were
further
synthesized into
major themes
and organized
according to the
four primary
concepts in the
conceptual
framework.
93
nurses in 29% of
events; support
personnel in
27% of events;
and management
in 2% of events.
Triggers, RN
responses, and
impacts on the
RN, patient, and
the nurse
practice setting
were also
identified.
Distraction from
patient care,
physical and
emotional
distress, and
priority conflicts
between patient
care and
operational
needs were
described by the
participants.
Concerns
regarding a
decrease in
quality care,
increased risk to
patient safety,
care delivery
delays, and
disrupted
working
relationships
were also
described.
may not represent
the experiences in
other hospital
settings. Despite the
limitations, the
study provides
insight into the
disruptive behavior
construct and
provides direction
for future inquiry of
disruptive behavior
in acute care
settings. The
authors
subsequently
followed up this
study with a
quantitative study
(see Walrath, Dang,
and Nyberg 2013)