Workplace violence and relational aggression are contributors to nurse burnout, turnover, and lack of engagement. By proactively addressing relational aggression and violence, organizations can have higher nurse engagement and reduce turnover intention (1). Healthcare organizations can work to improve the physical and emotional culture of safety within the workplace in the following ways:

• Start violence in the workplace initiatives with a safety assessment.
  • One such assessment uncovered in this work was the OAHHS toolkit (2). 
• Address security concerns promptly, including environmental, cultural, and perceived threats (1). 
• Engage in honest dialogue addressing disruptive behaviors, including individual and institutional racism (2,3). 
• Underscore professionalism is a part of being a competent nurse (4,5).
• Emphasize a supportive climate to build trust (1). 
• Let individuals know how their behavior impacts their colleagues, patients, and the work environment (6).
• Set clear expectations about acceptable behavior (7).
• Avoid ineffective leadership strategies such as rationalizing uncivil behavior (7, 3).
• Be willing to separate employees who continue to create a culture of incivility despite coaching, regardless of clinical practice experience (7).
• Implement multicomponent interventions that go beyond individual-level training to include organizational policies and work environment changes formed from collaborative discussions between direct care workers and management-level staff (8).

References:

1. Liu, W., Zhao, S., Shi, L., Zhang, Z., Liu, X., Li, L., Duan, X., Li, G., Lou, F., Jia, X., Fan, L., Sun, T., & Ni, X. (2018). Workplace violence, job satisfaction, burnout, perceived organisational support and their effects on turnover intention among Chinese nurses in tertiary hospitals: a cross-sectional study. BMJ Open, 8(6), e019525. https://doi.org/10.1136/bmjopen-2017-019525
2. Oregon Association of Hospitals and Health Systems with the Washington State Hospital Association, (2020). Stop Violence in Healthcare: A toolkit for prevention and management. Retrieved from OAHHS.org: https://oahhs.org/assets/documents/documents/safety/WPV/Toolkit%20all%20Sections%20with%20PDF%20index%20(no%20tools).pdf
3. Truitt, A. R., & Snyder, C. R. (2019). Racialized Experiences of Black Nursing Professionals and Certified Nursing Assistants in Long-Term Care Settings. Journal of Transcultural Nursing, 31(3), 312–318. https://doi.org/10.1177/1043659619863100
4. Adriaenssens, J., De Gucht, V., & Maes, S. (2015). Determinants and prevalence of burnout in emergency nurses: A systematic review of 25 years of research. International Journal of Nursing Studies, 52(2), 649–661. https://doi.org/10.1016/j.ijnurstu.2014.11.004
5. Fowler, M., PhD. (2015). Guide to the Code of Ethics for Nurses: With Interpretive Statements: Development, Interpretation, and Application (Second). American Nurses Association.
6. Thompson, R. (2022). Coping with Incivility: Steps to Move Toward a Supportive Culture. Voice of Nursing Leadership: American Organization for Nursing Leadership May 2022.
7. Sutton, R. I. (2007). The No Asshole Rule: Building a Civilized Workplace and Surviving One That Isn’t. Business Plus.
8. Somani, R., Muntaner, C., Hillan, E., Velonis, A. J., & Smith, P. (2021). A Systematic Review: Effectiveness of Interventions to De-escalate Workplace Violence against Nurses in Healthcare Settings. Safety and Health at Work, 12(3), 289–295. https://doi.org/10.1016/j.shaw.2021.04.004

Meaningful recognition perception has an inverse relationship to burnout and has been linked to job embeddedness increasing one’s perceived connection with peers and the organization (1, 2). How recognition is communicated plays a vital role in the perception of its significance. Organizations are encouraged to take a personal approach in determining what delivery method is meaningful to the “end user (1).” Once known, the recognition should be specific to an act or accomplishment, timely, delivered by someone professionally important to the individual, and aligned with the individual’s values. Delayed accolades or non-specific recognition efforts can be disingenuous (3, 4, 5). Steps to take to engage in meaningful recognition of frontline staff can include the following:

• Embed recognition efforts into workflows and formal processes that are known and encouraged throughout the organization (3).
  • Examples of processes are patient/client feedback forms, peer or manager nominations, recognition moments related to specific criteria, i.e., outcomes or performance targets, etc. (4).
• Equip managers with tools for delivering personalized recognition.
  • Recognition kits allow quick access to note cards and other essentials (4).
• Be specific when communicating gratitude (3).  
• Promote reflection, extend appreciation, and express confidence in the employee’s ability to perform well (5).
• Ask employees how they would like to be recognized (3).
• Clearly communicate how all organization members should be involved from bedside to boardroom (3).

References:

1. Kim, L. Y., Rose, D. E., Ganz, D. A., Giannitrapani, K. F., Yano, E. M., Rubenstein, L. V., & Stockdale, S. E. (2020). Elements of the healthy work environment associated with lower primary care nurse burnout. Nursing Outlook, 68(1), 14–25. https://doi.org/10.1016/j.outlook.2019.06.018
2. Cindy Lefton. (2012). Strengthening the workforce through meaningful recognition. Nursing Economics, 30(6), 331–338, 355. https://pubmed.ncbi.nlm.nih.gov/23346731/
3. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence (2nd ed.). (2016). American Association of Critical-Care Nurses. https://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf
4. Zwickel, K., Koppel, J., Katz, M., Virkstis, K., Rothenberger, S., & Boston-Fleischhauer, C. (2016). Providing Professionally Meaningful Recognition to Enhance Frontline Engagement. JONA: The Journal of Nursing Administration, 46(7/8), 355–356. https://doi.org/10.1097/nna.0000000000000357
5. Sherwood, G., Koshy Cherian, U., Horton-Deutsch, S., Kitzmiller, R., & Smith-Miller, C. (2018). Reflective practices: meaningful recognition for healthy work environments. Nursing Management, 24(10), 30–34. https://doi.org/10.7748/nm.2018.e1684

Allowing employees to be involved in decisions that impact their work increases engagement and strengthens the voice of individual contributors. True professional governance and shared decision-making have direct care staff at the core of decisions impacting their practice and patient care areas, increasing their autonomy and validating their professional competence (1). Things organizations can do to enhance professional governance and shared decision-making:

• Genuinely focus on relationship building, create a sense of common purpose and embrace collaboration (2).
• Evaluate current decision-making structures and processes to determine how practice-related decisions are made (1, 2)
• Fully invest in nurses collaborating with leaders to make decisions (shared decision-making) rather than requesting nurse input (participatory management) on policies and procedures impacting practice (1, 3, 5).
• Consider direct care level councils containing the following attributes:
  • Participants have personal accountability and ownership for their work (3). 
  • Decision-making is shared between the direct care team and management as collaborators focused on outcomes and goals for the populations served (1, 3, 5). 
  • Ensure councils have the education, resources, support, and protected time necessary to guide the practice environment and own the outcomes (1, 3, 4, 5, 6).
• Maintain bi-directional communication and feedback as plans and protocols are formulated (1, 2).
• Build leadership trust by supporting nurses in professional governance and clearly articulate expectations and authority levels (1, 3, 5, 6).

References:

1. ​​Orton, A. (2021). Supporting nursing autonomy through shared governance. Nursing Management, 52(12), 44–46. https://doi.org/10.1097/01.numa.0000800404.94545.fb
2. Owen, D., Boswell, C., Opton, L., Franco, L., & Meriwether, C. (2018). Engagement, empowerment, and job satisfaction before implementing an academic model of shared governance. Applied Nursing Research, 41, 29–35. https://doi.org/10.1016/j.apnr.2018.02.001
3. Clavelle, J. T., Porter O’Grady, T., Weston, M. J., & Verran, J. A. (2016). Evolution of Structural Empowerment. JONA: The Journal of Nursing Administration, 46(6), 308–312. https://doi.org/10.1097/nna.0000000000000350
4. Amberson, T., Graves, J. M., & Sears, J. M. (2022). Implementing the Total Worker Health Program in a Shared Governance Context. Journal of Emergency Nursing, 48(4), 342–347. https://doi.org/10.1016/j.jen.2022.05.004
5. Porter-O’Grady, T. (2019). Principles for sustaining shared/professional governance in nursing. Nursing Management, 50(1), 36–41. https://doi.org/10.1097/01.numa.0000550448.17375.28
6. Rodwell, J., McWilliams, J., & Gulyas, A. (2016). The impact of characteristics of nurses’ relationships with their supervisor, engagement and trust, on performance behaviours and intent to quit. Journal of Advanced Nursing, 73(1), 190–200. https://doi.org/10.1111/jan.13102

Nurses have experienced significant trauma since early 2020. Those working in emergency departments, critical care, medical-surgical, psychiatric, and mental health report higher stigma associated with seeking help. Studies indicate that nurses who may have a higher need for services, like other high-stress occupations, may be less likely to seek help. Organizations can take steps to normalize help-seeking behaviors through the following actions (1):

• Educate nurses about the signs and symptoms to get help (2) 
• Make health resources easy to access (3). 
• Do not ask nurses about a past or present history of mental health conditions or treatment (4).
• Limit common concerns to mental health and substance abuse help, such as confidentiality concerns, potential loss of license, or embarrassment over admitting a problem (5). 
• Do not penalize nurses for taking sick time for mental health reasons (4). 
• Remind teams that they are not alone (6).  
• Consider an opt-out method rather than opt-in for mental health services in high-risk areas (7).
• Provide free access to mental health resources, particularly during the workday (7, 8).
• Model behaviors that promote self-monitoring (4). 

References:

1. American Nurses Foundation (2021). American Nurses Foundation. (2021). Pulse of the nation’s nurses survey series: mental health and wellness taking the pulse on emotional health, post-traumatic stress, resiliency, and activities for strengthening wellbeing. https://www. nursingworld.org/~4aa484/globalassets/docs/ancc/magnet/ mh3-written-report-final.pdf
2. American Psychiatric Nurses Association (APNA). (2020). American Psychiatric Nurses Association (APNA). (2020). Nurses Guide to Seeking Mental Health Services . Retrieved from APNA.org: https://www.apna.org/files/public/NursesGuidetoSeekingMentalHealthServices_Final.pdf
3. Shapiro, D. E., Duquette, C., Abbott, L. M., Babineau, T., Pearl, A., & Haidet, P. (2018). Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level. The American Journal of Medicine, 132(5), 556–563. https://doi.org/10.1016/j.amjmed.2018.11.028
4. Quick Safety Issue 54. (2020). Retrieved June 27, 2022, from https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-54/
5. Cares, A., Pace, E., Denious, J., & Crane, L. A. (2014). Substance Use and Mental Illness Among Nurses: Workplace Warning Signs and Barriers to Seeking Assistance. Substance Abuse, 36(1), 59–66. https://doi.org/10.1080/08897077.2014.933725
6. Raza, B., St-Onge, S., & Ahmed, A. (2022). How help-seeking behaviors help reduce emergency nurses’ stress? International Emergency Nursing, 63, 101177. https://doi.org/10.1016/j.ienj.2022.101177
7. Shapiro, D.E., & Zangerle, C. (2022, April 11-14) Inspiring Leaders: 12 Recommendations from Studying Burnout, Violence, and Turnover . AONL 2022 Annual Conference, San Antonio, TX, United States
8. Schlak, A. E., Rosa, W. E., Rushton, C. H., Poghosyan, L., Root, M. C., & McHugh, M. D. (2022c). An expanded institutional- and national-level blueprint to address nurse burnout and moral suffering amid the evolving pandemic. Nursing Management, 53(1), 16–27. https://doi.org/10.1097/01.numa.0000805032.15402.b3

Nurses require personal space, privacy, quiet time, and preferably uninterrupted time out of the patient care area for meaningful rest breaks. Some ideal break spaces include:

• Access to nature, daylight, and fresh air (1).
  • Physical access to the outdoors is preferred over window access.
  • In break areas without access to the outdoors, plants can provide benefits. 
    • It’s important to note that posters and murals do not have the same restorative impact.
• Hydration and food access (2).
  • Make healthy food and snack options available to nursing staff 24/7. 
  • Promote healthy food choices at eye level and make them convenient to consume. 
  • Provide appropriate break lengths for staff to access and consume healthy food and to rehydrate.