Promoting a Culture of Safety and Healthy Work Environment

 Practice Considerations

The American Association of Nurse Anesthetists (AANA) encourages Certified Registered Nurse Anesthetists (CRNAs) to play an instrumental role in promoting a culture of safety and developing healthy work environments. Healthy work environments optimize patient safety, enhance staff’s physical and mental well-being, and help organizations sustain financial stability.
​The terms disruptive behavior, workplace violence, and workplace bullying are often used interchangeably. Horizontal violence and lateral violence are also considered synonymous. These terms depict behaviors that may be physically or emotionally harmful to the victim.
Workplace violence ​“Violence or the threat of violence against workers. It can occur within or
outside of the workplace and can range from threats and verbal abuse to
physical assaults and homicide.”1 
Disruptive behavior ​Characterized by insults, intimidation, verbal threats, humiliation, or sabotage. Other examples include, but are not limited to: sexual harassment; unresponsiveness; shouting; sarcasm; exclusion and intentionally distancing the target.2-5
Horizontal violence ​Describes negative behaviors among peers.
​Vertical violence ​Describes negative behaviors among individuals of varying status.
Barriers to a Culture of Safety and Healthy Work Environment
Workplace violence (WPV) and disruptive behaviors are barriers to fostering a culture of safety. WPV reportedly affects two million individuals each year, although it is believed many more cases are unreported. Healthcare workers, particularly nurses, are at an increased risk of experiencing this psychosocial phenomenon.6-9 Estimates suggest that more than 80 percent of nurses experience bullying during their careers and are often subjected to two or more incidents weekly.10-13 In light of this evidence, the World Health Organization considers workplace bullying a public health threat.14 Nurses working in the operating room (OR) experience higher levels of incivility among their peers and significantly more from supervisors than in other units (e.g., intensive care unit, medical surgical) and even greater levels of incivility from physicians.15
Workplace violence may extend to social media as cyberbullying and harassment.16,17 Social media provides an easily accessible forum for individuals to post messages anonymously to intimidate or spread rumors, threats and photos communicated widely and quickly. These threats should be reported quickly in order to prevent irreparable harm to the victim(s). Healthcare professionals should use good judgment when using social media in order to protect patient confidentiality and to preserve their own integrity and the integrity of their colleagues and institutions.
Risk Factors that Support Unhealthy Work Environments
It is estimated that healthcare workers are 16 times more likely to experience WPV than other professions.18 Healthcare workers practicing in the emergency, psychiatric, and intensive care units experience the highest levels of WPV. Students and new nurses are not immune to WPV and are at a greater risk of vertical violence due to their need for professional development and mentorship.12,13,19  Table 1 summarizes risk factors that contribute to unhealthy work environments.
Table 1. Risk factors that may support unhealthy work environments and relationships
Perpetrator8,19,20​ ​Staff6,8,12,13,19-23 ​Facility6,8,20-22,24,25
External (e.g., patients, visitors) Demanding caseload ​Leadership tolerance of WPV
​Substance abuse history Time pressures ​Low trust among team members
​Angry or anxious ​Extended work hours ​Limited resources
​Distressed ​Transporting patients ​High stress environments
​Mentally unstable ​Working understaffed ​Competitive environments
​History of violent behavior ​Inadequate training ​Poor workflow design
Internal (e.g., peers, supervisors) ​Role conflict among colleagues ​Poorly enforced visitor policy
​Previous victim of violence ​Poor relationships with peers ​Lack of WPV policy
​Skilled in manipulation ​Inadequate security
​Lack of self-esteem 
Impact of Unhealthy Workplace Behaviors
Disruptive behaviors, regardless of their intensity, are occupational health and safety hazards that may affect all members of a work system.12
Disruptive behaviors place patient safety at risk.26 Poor communication is a leading cause of patient dissatisfaction and adverse events.27 The 2013 Institute for Safe Medication Practices workplace intimidation survey found that half of respondents avoided clarifying a medication order with the prescriber if the physician was difficult to work with when clarifying an order in the past.28 A 2014 study found that as disruptive communication increased, so did errors and adverse events, impacting outcomes and the quality of care.10 Unmanaged conflict and disruptive behaviors impact patients through: 
  • Medication errors, patient injuries, and deaths19,29-31
  • Provider delaying communication or not communicating information to colleagues28
  • Lower overall quality of patient care31
  • Incomplete transfer of pertinent patient care-related information.26 
The impact of disruptive behavior to the worker is costly. Victims of WPV experience poorer states of physical health and mental health than their colleagues.10,22,30,32-35 Verbal abuse may have a deeper impact with long-term psychological effects than physical abuse.13 The symptoms and implications typically reported by individuals affected by WPV are summarized in Table 2.
Table 2. Symptoms experienced by targets of WPV and potential implications for individual staff   
Physical symptoms36 ​Mental Symptoms12,13,19,22,24,26,30-32,36 Implications6,10,22,29-31,34,37,38
​Physical pain ​Stress or anxiety ​Reduced morale
​Digestive disorders ​Post-traumatic Stress Disorder ​Disengaged
​Depression ​Unmotivated
​Loss of self-esteem ​Resentful
​Impaired short-term memory ​Intent to leave
​Inability to focus and concentrate ​Decrease in job satisfaction
​Disturbed sleep patterns
Students & New Graduates
Student nurses who are affected by WPV, unlike experienced nurses, report an increased desire for revenge.13 Workplace bullying specifically threatens graduates of healthcare profession educational programs as they transition into their new roles. Graduate nurses may endure stressful conditions that lead to burnout during their first year in clinical practice.22,39 They often experience abuse from internal sources (staff, preceptor, physicians, and their direct supervisors) and external sources (patients, visitors), while the perpetrator of abuse against experienced nurses is often internal.13 Regardless of the target, the psychological effects of WPV are most significant when the perpetrator is a staff member.13
Healthcare Facility
Facilities are directly impacted by unhealthy work environments due to the damaging effects on workers. Individuals are more likely to leave their job or profession if they are dissatisfied.13,23,32,34,40  The organization’s financial burden is estimated to be between $30,000 to $100,000 annually per victim due to these destabilizing factors:12  
  • Staff turnover11,12,21,30,34,36,37
  • Focus away from organizational goals11,12,21,30,34,36,37
  • Absenteeism and tardiness12,21,24,32,37
  • Psychological treatment12
  • Decreases in organizational commitment, team performance, and work output6,12,15,24,29,30,32,34,40
  • Potential for increased risk of liability associated with a reduction in patient safety26 
Promoting a Culture of Safety and Healthy Work Environment
Employers and employees have an opportunity and responsibility to foster a safe work environment free from distracting, disruptive or violent behaviors. Programs to prevent workplace violence improve the work environment, job satisfaction, staff retention, productivity, and quality of care.24  Ongoing education related to the organization’s mission, values and code of conduct, as well as communication skills development, guide the individual to choose the most appropriate response when faced with WPV. Despite the estimated prevalence of WPV, approximately 70 percent of United States institutions do not have programs or policies to address it.
Developing effective policies and leadership accountability will support change in an organization. A change in leadership attitudes, responses, and initiatives is only a first step. An effective healthy work environment program requires a multifaceted approach to continuously improve engagement. Considerations include: 
  1. Organizational Assessment21,41
    An assessment of the workplace culture of safety provides a baseline for analysis of the existing environment to identify priorities for improvement.21,41 The Occupational and Safety Health Administration (OSHA) guidelines recommend an organization-wide assessment, facility or provider risk identification, management commitment, employee involvement through staff and supervisor training, and well-documented written records to prevent WPV.42 Additional security (e.g., cameras), staffing measures, and other facility-specific recommendations may be warranted after an assessment is conducted.

  2. Organizational Policies and Resources
    Code of Conduct25,43
    An organizational code of conduct supports the culture of safety by defining acceptable and inappropriate behaviors as well as a process to hold staff accountable for behaviors that undermine the culture of safety. The Code of Ethics for the Certified Registered Nurse Anesthetists guides CRNAs in their professional obligation to be accountable for their own conduct and integrity in their relationships with other healthcare providers.44  
Zero-Tolerance for Violence Policy21,25,36-38,45
In 2003 and 2004, the National Institute for Occupational Safety and Health and OSHA recommended that healthcare organizations provide a safe environment for their employees.42,46 A zero-tolerance for violence policy in combination with a code of conduct can help organizations minimize abuse and possible harm to their employees. The AANA supports and promotes a culture of safety through the development of comprehensive facility policies for the prevention of violent or disruptive behaviors.  
Initial, Ongoing and Post-event Employee Support43
An Employee Assistance Program (EAP), clergy, peer support program, or counselor may provide support to staff coping with stressful situations. The AANA Guidelines for Critical Incident Stress Management detail considerations for facilities, healthcare providers and individuals seeking resources about managing stress following an adverse event.47 
  1. Ongoing Staff Education, Communication, Conflict Management and Resolution, Stress Management, and Wellness21,25,43
    Staff education, training and continuing education opportunities are necessary to help an individual identify, understand, address, cope with, and recover from behaviors that are disruptive or inappropriate.12,21,35 Research supports staff education in communication skills, stress management, and conflict management and resolution.
A culture of safety blossoms when staff is personally equipped and supported by leadership with tools for clear communication and conflict management and resolution to help them deal with inappropriate behavior.29,36
  1. Culture of Safety48
    Safety culture develops when leadership demonstrates a commitment to culture change by their own behavior, provides resources that achieve results, and openly shares safety information. Staff engages in a culture of safety when they take direct, personal action to address safety issues.
    • Modeling Appropriate Behavior12,15,21,43
      Leadership and staff who demonstrate respect and model respectful conduct improve an organization’s culture of safety.21,24 Leaders who embrace and model positive behavior towards others show that unacceptable behavior has no place in their organization.24
    • Staff Mentorship11,12
      Positive mentorship of new staff establishing the expectations for acceptable conduct.11 Negative or ineffective mentoring is linked to decreased job satisfaction of mentees and to an increase in the  risk of errors in patient care.49 Preceptor and mentorship programs improve the transition for new nurse graduates into clinical practice and decrease preceptor stress associated with the increased workload of mentoring.29
    • Open Communication throughout the Organization41 
      Open dialogue between leadership and staff reduces conflict and is vital to patient safety.29
      Discussing situations and their solutions improves trust and communication, decreases disruptive behavior, and supports resolution of the inappropriate behavior.29 It is important to address WPV behaviors as close to the time of occurrence as possible.12 Creating an environment of open communication improves job satisfaction and creates a healthy work environment.21,29 Staff retention rates are also better in hospitals with self-identified higher levels of communication quality.29
Facilitated discussion between those involved in a WPV experience may be necessary
to understand the issue, and to resolve and prevent future disruptive behavior.
Strategies for meeting with the abuser may include these action steps:
        • Leadership determines if a facilitated conversation is indicated to resolve the issue.
        • Identification of the root causes of the event/behavior.
        • Development and agreement on the plan of action.
        • Evaluation of progress.
        • Communication of appreciation of each other’s willingness to resolve the conflict.21
  1. Quality Improvement Processes9,12,25,36,43
    A facility-specific quality improvement process should be in place to assist staff in reporting acts of WPV.43 A culture of safety grows when workers are able to report WPV incidents and bullying without fear of retribution and criticism from peers or leadership. Half of all participants in both the 2007 and 2012 Agency for Healthcare Research and Quality’s Safety Culture Surveys reported that they feel mistakes are held against them, and 65 percent worried that the mistakes would be retained in their personnel files. Additional barriers to reporting acts of WPV include:13,20
    • Lack of physical injury
    • Lack of administrative support
    • Fear of receiving negative feedback or evaluation
    • Inconvenience of the reporting process
    • Ambiguous reporting policies
    • Fear of retaliation
    • Acceptance of violence or disruptive behavior
    • Fear of being seen as weak or incompetent
Reporting acts of WPV is necessary to identify and investigate disruptive behaviors and to create a healthy work environment.
Visit the AANA’s Wellness in the Workplace website located at for additional information and resources on:
  • Disruptive behavior and workplace incivility
  • Safety in the workplace
  • Stress management
  • Workplace ergonomics
  • Career transitions 
The rapidly changing demands and expectations of healthcare magnify the importance of the culture of safety and code of conduct to minimize disruptive and inappropriate behaviors that may place patients and fellow staff at risk of harm. The AANA encourages CRNAs to contribute to the development and continuous improvement of healthy work environment policies and behaviors.
  1. What is Workplace Violence? Who is Vulnerable? OSHA Fact Sheet. Accessed August 9, 2002.
  2. Martin WF. Is your hospital safe? Disruptive behavior and workplace bullying. Hosp Top. Summer 2008;86(3):21-28.
  3. Moayed FA, Daraiseh N, Shell R, Salem S. Workplace bullying: A systematic review of risk factors and outcomes. Theoretical Issues in Ergonomics Science. 2006;7:311-327.
  4. Simons S. Workplace bullying experienced by Massachusetts registered nurses and the relationship to intention to leave the organization. ANS Adv Nurs Sci. Apr-Jun 2008;31(2):E48-59.
  5. Hauge LJ, Skogstad A, Einarsen S. Relationships between stressful work environments and bullying: Results of a large representative study. Work and Stress. 2007;21:220-242.
  6. Ariza-Montes JA, Muniz RN, Leal-Rodriguez AL, Leal-Millan AG. Workplace bullying among managers: a multifactorial perspective and understanding. Int J Environ Res Public Health. Mar 2014;11(3):2657-2682.
  7. Lim FA, Bernstein I. Civility and workplace bullying: resonance of Nightingale's persona and current best practices. Nurs Forum. Apr-Jun 2014;49(2):124-129.
  8. Bentley TA, Catley B, Forsyth D, Tappin D. Understanding workplace violence: the value of a systems perspective. Appl Ergon. Jul 2014;45(4):839-848.
  9. Harding AD. Education and culture: mitigation for workplace violence. J Emerg Nurs. May 2011;37(3):256-257.
  10. Purpora C, Blegen MA, Stotts NA. Hospital staff registered nurses' perception of horizontal violence, peer relationships, and the quality and safety of patient care. Work. Jun 16 2014.
  11. Frederick D. Bullying, mentoring, and patient care. AORN J. May 2014;99(5):587-593.
  12. Becher J, Visovsky C. Horizontal violence in nursing. Medsurg Nurs. Jul-Aug 2012;21(4):210-213, 232.
  13. Magnavita N, Heponiemi T. Workplace violence against nursing students and nurses: an Italian experience. J Nurs Scholarsh. Jun 2011;43(2):203-210.
  14. Laschinger HK. Impact of workplace mistreatment on patient safety risk and nurse-assessed patient outcomes. J Nurs Adm. May 2014;44(5):284-290.
  15. Smokler Lewis P, Malecha A. The impact of workplace incivility on the work environment, manager skill, and productivity. J Nurs Adm. Jul-Aug 2011;41(7-8 Suppl):S17-23.
  16. Mansfield SJ, Morrison SG, Stephens HO, et al. Social media and the medical profession. Med J Aust. Jun 20 2011;194(12):642-644.
  17. Cyberbullying and Harassment. Accessed August 28, 2014.
  18. Workplace Violence in Healthcare Settings. Accessed August 20, 2014.
  19. Reynolds G, Kelly S, Singh-Carlson S. Horizontal hostility and verbal violence between nurses in the perinatal arena of health care. Nurs Manag (Harrow). Feb 2014;20(9):24-30.
  20. Strickler J. When it hurts to care: workplace violence in healthcare. Nursing. Apr 2013;43(4):58-62.
  21. Clark CM. National study on faculty-to-faculty incivility: strategies to foster collegiality and civility. Nurse Educ. May-Jun 2013;38(3):98-102.
  22. Spence Laschinger HK, Wong CA, Grau AL. The influence of authentic leadership on newly graduated nurses' experiences of workplace bullying, burnout and retention outcomes: a cross-sectional study. Int J Nurs Stud. Oct 2012;49(10):1266-1276.
  23. Dumont C, Meisinger S, Whitacre MJ, Corbin G. Nursing2012. Horizontal violence survey report. Nursing. Jan 2012;42(1):44-49.
  24. Sanner-Stiehr E, Ward-Smith P. Lateral violence and the exit strategy. Nurs Manage. Mar 2014;45(3):11-15.
  25. McNamara SA. Workplace violence and its effects on patient safety. AORN J. Dec 2010;92(6):677-682.
  26. Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. Jul 2006;203(1):96-105.
  27. Mullan CP, Shapiro J, McMahon GT. Interns' experiences of disruptive behavior in an academic medical center. J Grad Med Educ. Mar 2013;5(1):25-30.
  28. Disrespectful Behaviors Their Impact, Why They Arise and Persist, and How to Address Them. 2014; Accessed August 13, 2014.
  29. Brinkert R. A literature review of conflict communication causes, costs, benefits and interventions in nursing. J Nurs Manag. Mar 2010;18(2):145-156.
  30. Spence Laschinger HK, Nosko A. Exposure to workplace bullying and post-traumatic stress disorder symptomology: the role of protective psychological resources. J Nurs Manag. Sep 3 2013.
  31. Hutchinson M, Jackson D. Hostile clinician behaviours in the nursing work environment and implications for patient care: a mixed-methods systematic review. BMC Nurs. 2013;12(1):25.
  32. Hansen AM, Hogh A, Garde AH, Persson R. Workplace bullying and sleep difficulties: a 2-year follow-up study. Int Arch Occup Environ Health. Apr 2014;87(3):285-294.
  33. Brown LP, Rospenda KM, Sokas RK, Conroy L, Freels S, Swanson NG. Evaluating the association of workplace psychosocial stressors with occupational injury, illness, and assault. J Occup Environ Hyg. Jan 2011;8(1):31-37.
  34. Chang CH, Lyons BJ. Not all aggressions are created equal: a multifoci approach to workplace aggression. J Occup Health Psychol. Jan 2012;17(1):79-92.
  35. Radoslovich NA. Bullying in the health care environment. Plast Surg Nurs. Apr-Jun 2014;34(2):70-71.
  36. Morris K. Lateral violence in the workplace: fact or fiction? Ohio Nurses Rev. Jan-Feb 2012;87(1):6-7.
  37. Law R, Dollard MF, Tuckey MR, Dormann C. Psychosocial safety climate as a lead indicator of workplace bullying and harassment, job resources, psychological health and employee engagement. Accid Anal Prev. Sep 2011;43(5):1782-1793.
  38. Chipps EM, McRury M. The development of an educational intervention to address workplace bullying: a pilot study. J Nurses Staff Dev. May-Jun 2012;28(3):94-98.
  39. Chipas A, Cordrey D, Floyd D, Grubbs L, Miller S, Tyre B. Stress: perceptions, manifestations, and coping mechanisms of student registered nurse anesthetists. AANA J. Aug 2012;80(4 Suppl):S49-55.
  40. Schat A, Frone MR. Exposure to Psychological Aggression at Work and Job Performance: The Mediating Role of Job Attitudes and Personal Health. Work Stress. Jan 1 2011;25(1):23-40.
  41. Fontaine DK, Koh EH, Carroll T. Promoting a healthy workplace for nursing faculty and staff. Nurs Clin North Am. Dec 2012;47(4):557-566.
  42. Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. Accessed September 16, 2009.
  43. Gillespie GL, Gates DM, Mentzel T, Al-Natour A, Kowalenko T. Evaluation of a comprehensive ED violence prevention program. J Emerg Nurs. Jul 2013;39(4):376-383.
  44. Code of Ethics for the Certified Registered Nurse Anesthetist. Park Ridge, IL: American Association of Nurse Anesthetists; 2010.
  45. Hutchinson M. Bullying as workgroup manipulation: a model for understanding patterns of victimization and contagion within the workgroup. J Nurs Manag. Apr 2013;21(3):563-571.
  46. Workplace Violence Once Again in the Spotlight. 2003; Accessed August 29, 2014.
  47. Guidelines for Critical Incident Stress Management. Park Ridge, IL: American Association of Nurse Anesthetists; 2014.
  48. Develop a Culture of Safety. Accessed August 28, 2014.
  49. Topa G, Guglielmi D, Depolo M. Mentoring and group identification as antecedents of satisfaction and health among nurses: what role do bullying experiences play? Nurse Educ Today. Apr 2014;34(4):507-512.
  50. Patient-Centered Care: CRNAs and the Interprofessional Team. Park Ridge, IL: American Association of Nurse Anesthetists; 2012. 

In August 2000, the AANA Board of Directors adopted Position Statement 1.10, Workplace Violence and Disruptive Behavior. This position statement was revised by the AANA Board of Directors in June 2010. In September 2014, the AANA Board of Directors archived this position statement and adopted the Promoting a Culture of Safety and Healthy Work Environment, Practice Considerations.
© Copyright September 2014