Chapter 25: Workplace Violence and Incivility


Chapter 25: Workplace Violence and Incivility
Yoder-Wise: Leading and Managing in Nursing, 6th Edition


1. Your healthcare organization places a high value on workplace safety and integrates this into all aspects of administrative and patient care processes. As a unit manager, you thoroughly endorse this direction, and during the selection and hiring of new staff, you consistently:
a. Refuse to hire applicants who are pushy during interviews.
b. Thoroughly follow up with all references before offering a position.
c. Ask applicants during the interview if drug or alcohol abuse is a problem.
d. Refuse to interview applicants with sporadic work histories.
Determining if current employees pose a danger in the workplace is a critical factor that is often overlooked. In addition to personal and psychological factors, behaviors can be observed in employees that may be related to violence or aggression in the workplace (Paludi, Nydegger, & Paludi, 2006). The most obvious indicator is a previous history of aggression and substance abuse. Screening potential employees through drug testing, background checks, and references can help reduce the risk of hiring someone who may pose a danger in the workplace.

REF: Page 469 | Page 470 TOP: AONE competency: Business Skills

2. You need to terminate Gregory, who has had a long-standing history of conflict with you and the staff, and who recently was charged with theft of patient belongings. You consult Human Resources, and together, you develop a plan, which includes:
a. A private meeting with Gregory, a Human Resources representative, and you to deliver the news and deliver the termination notice and all other documents that are related.
b. Planning an opportunity for Gregory to return and be recognized at a staff farewell.
c. Calling Gregory at home to tell him that he is fired and that his paperwork will be sent to him at a future date.
d. Calling him into a meeting in your office on the ward, where assistance is available, should he become upset or agitated.
Termination requires careful planning as to timing, privacy, safety, and how to preserve the employee’s dignity and avoid humiliation. Choosing a private location where colleagues are not present, and organizing all documentation that is required to be given to Gregory, achieves these goals and prevents his having to come to the organization at a future date.

REF: Page 469 TOP: AONE competency: Business Skills

3. In which of the following situations would you, as the head nurse, be concerned about potential safety issues?
a. Jordan comes to your office to complain about inadequate staffing on the unit. He says that he is concerned because he attributes a recent incident to the staffing levels.
b. Henry, a long-standing RN on the unit, has begun to miss work regularly. He calls in but is vague about his reasons for the absences.
c. Carla, RN, has just ended an abusive relationship with Jake, RN, and he will not leave her alone. You are meeting with Jake today because colleagues on nights have reported that Jake seems to have been intoxicated last night and the previous night.
d. Sarah is very quiet and says almost nothing in team meetings. Lately, she has been much more animated since becoming friendly with a couple of other RNs on the unit.
Jake seems at most risk for violence because of his alcohol use and history of aggression. In the other situations, Jordan is expressing a legitimate concern and is behaving assertively; Henry may have health concerns or other issues that are private and interfering with his work life; and Sarah’s change in behavior is likely related to a higher level of comfort with work and colleagues.

REF: Page 470 TOP: AONE competency: Business Skills

4. Delaney, one of your staff nurses, confides that Marjorie, another nurse, has been actively telling others that you are incompetent and do not know what you are doing in relation to patient care, and that you lie to the staff about attempts to get more staffing. Delaney says that Marjorie is derogatory towards her in front of others and tells her “that she better shape up.” Through telephone calls and conversations during breaks, she is recruiting other staff to her position. Delaney confides that most of the staff find you fair, honest, and knowledgeable. Marjorie’s behavior can best be characterized as:
a. Political action.
b. Bullying.
c. Building alliances.
d. Disgruntlement.
Workplace bullying involves aggressive and destructive behaviors such as running a smear campaign, engaging in put-downs, and excluding team members from socialization opportunities.

REF: Page 465 | Page 473 TOP: AONE competency: Business Skills

5. During coffee and other breaks, Rosalie, the new RN, is shut out of conversations with the other staff. When she approaches other staff on the unit to ask questions, they turn and walk off in the other direction. The behavior of the staff is characteristic of:
a. Dislike.
b. Lack of trust in Rosalie’s abilities.
c. Horizontal violence.
d. Cultural incompetence.
Horizontal or lateral violence and bullying are terms used to describe destructive behaviors towards co-workers, such as the “silent treatment” and shutting others out of socializing.

REF: Page 465 | Page 473 TOP: AONE competency: Business Skills

6. While working with an aggressive patient, it is important for the nurse to:
a. Speak firmly.
b. Call the individual by name.
c. Place herself between the patient and the door.
d. Ignore threats against her.
In situations where a patient may become aggressive, it is important to ensure that you are not trapped in the room.

REF: Page 479 | Page 480
TOP: AONE competency: Knowledge of the Health Care Environment

7. Caroline asks family members to leave while she cares for the 16-year-old victim of a recent car accident. The father screams at her and tells her that she has no right to ask his family to leave, and that if she continues to do so, he will “throw her out of the room.” Caroline is shaken and tells her head nurse, who tells her that this kind of thing is just part of the job. The guidance of the head nurse:
a. Is reasonable. No physical violence was involved.
b. Is related to why statistics on violence in health care are likely underreported.
c. Acknowledges the deep distress and fear of the family.
d. Acknowledges the concern of the nurse.
A common perception is that incidences such as these, which do not involve physical injury or harm, but rather threats, are part of the job. Because of underreporting, data related to violence and aggression in the workplace may not be reflective of its true incidence.

REF: Page 465 TOP: AONE competency: Knowledge of the Health Care Environment

8. You are part of a multidisciplinary team that is charged with designing a workplace safety plan for your healthcare organization. This team has been established in response to increases in reports of violence and aggression. You begin by:
a. Surveying staff about levels of satisfaction with the workplace and management, collegial, and patient relations.
b. Offering training sessions in self-defense.
c. Developing a policy that outlines zero tolerance for bullying.
d. Offering education sessions on recognizing behaviors with potential for violence.
Violence and aggression and a toxic workplace can lead to staff dissatisfaction and high staff turnover rates. Surveying staff provides a useful starting place in identifying problems such as employee dissatisfaction, bullying, and other forms of violence.

REF: Page 468 | Page 471 TOP: AONE competency: Business Skills

9. In the Emergency Department waiting room, you notice a patient sitting, with his head in his hands, who has been waiting for about 5 hours for relief of his headache. When you approach him to ask him how he is doing, he says, “I can’t believe that I have to wait this long for help! Do you know what it is like to be in pain for 10 hours?” Your response to him would be:
a. “It is frustrating to wait when you are in pain and when you are expecting to receive relief right away.”
b. “Don’t talk to me. If you are going to be rude, then you will not receive treatment here.”
c. “We are very busy and don’t have enough staff to deal with problems such as yours.”
d. “Perhaps you should go elsewhere. We do not have time for you here, as many more sick patients are waiting.”
Empathizing helps the other person to know and feel that he has been understood and is powerful in de-escalating a situation that has potential for aggression and violence.

REF: Page 479 | Page 480
TOP: AONE competency: Communication and Relationship-Building

10. At 3 AM, a man walks into your emergency department. He paces back and forth in the waiting area before he approaches staff to ask if he can see his wife, who is a patient on another floor. He speaks rapidly, his face is flushed, he glances around often, and he keeps his hand in his jacket pocket. A best initial response would be to:
a. Assess your situation and your surroundings.
b. Ask two or three staff to assist in confronting the individual.
c. Ask what floor his wife is on and remind him that visiting hours are closed.
d. Remain calm as there is no potential for violence here.
The behavior of the individual (flushed appearance, furtive glances, speed of speech) and the hand in his pocket suggest the potential for violence or aggression. The first step is to quickly assess your surroundings for others who might assist and for safety alarms.

REF: Pages 39-40 | Pages 81-82
TOP: AONE competency: Knowledge of the Health Care Environment

11. Linda, a staff nurse on nights, yells at Ali, another RN, and tells Ali that she is stupid and can’t get anything right. In responding to this situation as head nurse, it is critical that you:
a. Require that Linda attend anger management classes.
b. Investigate to see if Ali did anything to aggravate Linda.
c. Call both immediately into the office to discuss the situation.
d. Respond to Linda in a way that is consistent with organizational processes and with similar situations.
Erratic or arbitrary discipline, favoritism, or behavior that undermines the dignity of either individual undermines efforts at curbing workplace violence. Disciplinary actions must be proportionate, consistent, reasonable, and fair.

REF: Page 475 TOP: AONE competency: Business Skills

12. Residents in a new long-term care facility attend a large dining hall for meals. In reviewing reports of aggression and violence, you note that behaviors such as hitting, or attempting, to hit staff are increasing. Further investigation suggests that this behavior occurs most often at mealtimes. A possible intervention would be to:
a. Seat residents with the highest potential for violence next to those with the lowest potential for aggression.
b. Feed residents earlier in the day.
c. Restrain residents who are violent or aggressive during mealtimes.
d. Establish a smaller dining area that is away from the main area that is for residents who have potential for aggression/violence.
Violence and aggression are more likely during times of increased activity, such as mealtimes. Reducing activity levels through interventions such as a separate dining area may reduce incidents of violence and aggression.

REF: Pages 468-469
TOP: AONE competency: Knowledge of the Health Care Environment

13. You note that Unit 64 has had a high turnover rate of staff during the past year. In investigating this situation, an important source of data might include:
a. Employee evaluations.
b. Level of experience of staff.
c. Exit interviews with staff.
d. Selection processes and decisions.
Exit interviews may assist in identifying issues such as workplace violence, bullying, and intimidation by managers.

REF: Page 471 | Page 472 TOP: AONE competency: Business Skills

14. You note that Unit 64 has had a high turnover rate of staff during the past year. In selecting the appropriate action, it is important that:
a. All documentation is reviewed.
b. Usual processes for discipline are followed.
c. Confidentiality is assured.
d. An incident report is filed.
Confidentiality is important if an employee fears intimidation or retribution from a manager.

REF: Page 471 TOP: AONE competency: Communication and Relationship-Building

15. You note that Unit 64 has had a high turnover rate of staff during the past year. In addressing the staff turnover rate, you are:
a. Confirming the high correlation between managerial incompetence and violence.
b. Demonstrating awareness that workplace violence, if present, has significant costs.
c. Aware that staff and manager experiences contribute to high turnover.
d. Aware that violence is a rare but present factor in the workplace.
Workplace violence and aggression contribute to staff turnover and toxic work environments. Loss of the organizational investment required to train new staff and departure of experienced staff can increase operating costs and reduce the quality of care.

REF: Page 468 TOP: AONE competency: Business Skills

16. A patient who has a history of involvement with drugs and weapons comes up to you in the hallway and asks you a question regarding directions in treatment. When you respond, he moves closer in to you and puts both hands up on either side of your neck. No one else is in the hallway. Your best response at this point is to:
a. Yell at him to stop.
b. Calmly ask the patient to remove his hands.
c. Hit the patient in the midsection.
d. Use pepper spray.
In a potentially violent situation, it is important to look and behave in a calm and confident manner, even if you do not feel calm or confident. The person that you are de-escalating will notice and take his cues from you.

REF: Page 478 TOP: AONE competency: Communication and Relationship-Building

17. Jenny tells you that she is always able to tell when others are about to become violent because they yell. Your response to Jenny is based on your understanding that:
a. Her perception is accurate.
b. Yelling is more likely associated with aggression.
c. Violence is signaled by a variety of behaviors.
d. She is mostly accurate in her thinking.
The STAMP Assessment Components and Cues outline a wide variety of verbal and nonverbal cues that might signal the potential for violence.

REF: Page 476 | Page 478 TOP: AONE competency: Business Skills

18. Joe and Carol, two of the RNs on Unit 22, are discussing recent incidents on the unit that have involved patients and visitors uttering threats or making demeaning remarks to staff during evening hours. Joe observes that unless someone shoots at him, he is not concerned because “words can’t hurt you.” Joe’s remarks:
a. Illustrate common misperceptions about the nature of violence.
b. Accurately depict the difference between violence and aggression.
c. Are partially correct because verbal remarks do not cause injury.
d. Reveal possible issues that Joe relates to violence in his personal life.
Violence and aggression involve verbal and nonverbal and covert and overt behaviors, and all forms are capable of producing short- and long-term injury that may have an impact on productivity, work performance, work attendance, and patient care.

REF: Page 464 | Page 465 TOP: AONE competency: Business Skills

19. Becky, RN, works as a staff nurse in mental health; Sharon works as a data entry clerk in Admissions; Sarah is an emergency room physician; and Donna is a housekeeper in geriatrics. Which of these four is most at risk for violence and aggression?
a. Becky
b. Sarah
c. Sharon
d. Donna
Healthcare workers, especially nurses, experience a disproportionately high rate of violence, compared to personnel in other industries. Nurses are the primary target of violence in healthcare settings, especially those who work in emergency room, mental health, and geriatrics. Hader (2008) found that nurses experienced their colleagues as primary targets of violence 79.7% of the time.

REF: Page 465 | Page 468 | Page 469 TOP: AONE competency: Business Skills

20. Which of the following healthcare employees is MOST at risk for violence?
a. Becky, working in a well-lit area with stable psychiatric patients and other staff members nearby.
b. Sarah, who works in a busy emergency room. Access to the emergency patient units is allowed by security staff and alarm systems are in place in patient units.
c. Sharon, who works evening shifts. Workstation is behind a shatterproof glass, and an alarm can be reached easily from her computer.
d. Donna, who works the evening shift, cleans rooms each night in the administrative wing and business offices, which are largely empty. The wing is near an outside access door.
Staff who work in isolated, poorly lit areas are at higher risk of violence, which would describe Donna’s work conditions. In addition, if the business office contains money, this could make it a desirable target for criminals. While Becky and Sarah work in high-risk areas (mental health and the emergency room), the nearby presence of colleagues, the availability of alarms, and good lighting help to reduce the risk.

REF: Page 468 TOP: AONE competency: Business Skills

21. A safety and security plan is important to a healthcare organization because it:
a. Lays out preventive measures in relation to violence.
b. Provides direction as to changes in facilities that protect staff.
c. Establishes expectations in relation to behavior and tolerance of violence.
d. Establishes policies and practices that guide prevention of violence and expectations in the workplace.
A safety plan provides overall direction in relation to what is expected, how violence is prevented, and what will occur when violence happens.

REF: Page 471 | Page 472 TOP: AONE competency: Business Skills

22. Sarah is involved in intervening when a patient attempts to harm herself on the unit. During the interaction, the patient slaps Sarah across the face. As a head nurse, it is important that you:
a. Offer Sarah immediate education and training in self-defense.
b. Assist with follow-up documentation and offer access to counseling.
c. Provide access to a lawyer.
d. Encourage Sarah to see the incident as a normal part of care.
Training should be conducted on a regular basis and cover a variety of topics, including policies and procedures for reporting, record-keeping, and for obtaining medical care, counseling, workers’ compensation, or legal assistance after a violent episode or injury.

REF: Page 477 TOP: AONE competency: Business Skills

23. Which of the following is NOT a factor in patient- and/or family-generated violence in healthcare settings?
a. Feelings of vulnerability
b. Anxiety about treatments or diagnoses
c. Feelings of powerlessness or loss of control
d. Staff rudeness
Unlike in other settings, hospital violence differs in that it is usually the result of patients or their family members feeling frustration or anger. This is usually related to feelings of vulnerability, stress, and loss of control that accompany illness. Other factors such as the location, size of the facility, and type of care provided also increase the risk for violence.

REF: Page 468 | Page 469 TOP: AONE competency: Business Skills

24. As a nurse manager, you realize that your unit has become a toxic environment in which horizontal violence and incivility has become common. In addressing the problem, you decide to implement which of the following?
a. Increased education in clinical skills
b. Follow-up of all reports of violence
c. Training in conflict resolution and team-building
d. Posting of the institutional policy on violence at the nursing station
Encouragement to report violence in all its forms is crucial to understanding the root of the problem and implementing plans to eradicate it. Acts of good faith by organizational management in supporting staff include a policy of non-retaliation for reporting. Making sure that reporting is easier and doing an impartial investigation are critical. Addressing a toxic culture also requires training in conflict management, leadership, communication, and team-building.

REF: Page 471 | Page 473 TOP: AONE competency: Business Skills

25. As a senior manager, you notice that there have been several resignations on a unit where a new charge nurse has been hired. You suspect that the new charge nurse may be demonstrating bullying behaviors, but staff say little about their relationship with the charge nurse. Your decisions about intervention would be based on which assumptions?
a. The staff nurses would tell you if the charge nurse was engaging in relational violence.
b. It would be unusual for leaders to engage in violence and bullying behavior.
c. Bullying is primarily related to feelings of marginalization and jealousy among peers.
d. Initiating confidential exit interviews will assist in determining if leader violence or bullying is occurring.
To understand if violence or intimidation is a reason for leaving, organizations should conduct exit interviews with the assurance that the information will remain confidential if an employee fears retaliation. This is an important step in gauging if the problem is bullying or intimidation by managers. Johnson (2009) found that 50% of respondents indicated that they were bullied by their manager or director. The researcher suggested that when management is part of the problem, victims have a harder time feeling they have adequate support to end the negative cycle of violence. Lack of support leads many victims of bullying to decide that the best alternative is to leave the organization and to give this advice to others who find themselves in similar situations (Johnson, 2009).

REF: Page 471 | Page 472 TOP: AONE competency: Business Skills


1. In designing a new healthcare facility, it is particularly important to pay close attention to safety elements related to violence and aggression in which of the following settings? (Select all that apply.)
a. Emergency
b. Psychiatry
c. Gerontology
d. Maternal-child
ANS: A, B, C
Although the potential for violence and aggression exists in all healthcare settings, emergency, psychiatric, and geriatric settings are at particular risk for violence.

REF: Page 468 TOP: AONE competency: Knowledge of the Health Care Environment