Power point – nik

Choose Topic Provided Below:

TOPIC: “Impact of workplace harassment and violence on the nursing profession”

You must use the ATTACHED PowerPoint presentation template

1. You are to create bullet points for each slide, not including the title and reference slides. 

2. Every slide must have a speaker note with a minimum of 4-5 sentences addressing the bulleted items on the slide.

3. Include Below Provided references for the presentation. 

4. All research articles that you need to use are attached below. 

The PowerPoint presentation must follow current APA style

  1. Your presentation should include the following slides:
    1. Title slide
    2. Why the topic was chosen
    3. How your topic impacts nursing practice
    4. Current relevance of the topic
    5. Clinical Practice Integration
    6. Plan for lobbying: Describe in detail your plan for how you would lobby your legislators or local government for funding and support for your chosen current issue or trend.
    7. Conclusion
    8. Reference slide

NURS 440 PowerPoint Template

Student Name

School

Course

Faculty Name/Title

Date

* You may change the color & background and remember to include colorful, visual illustrations (i.e. data,

graphs, clip arts, embedded video etc…) appropriate to engage your audience!

Use this template to complete your presentation. You may change the color & background, but the following headings must remain:

Slide 1 – Title

Slide 2 – Why the Topic Was Chosen

Slide 3 – How the Topic Impacts Nursing

Slide 4 – Current Relevance

Slide 5 – Clinical Practice Integration

Slide 6 – Plan For Lobbying

Slide 7 – Conclusion

Slide 8 – References

Include speaker notes for each slide by including 4-5 sentences to address the bulleted items on each slide. Please follow APA style and include citations in your speaker notes.

Each slide should have an image.

1. Explain why you chose your topic, referring to assignment guidelines.

2. Why is this topic meaningful to you?

3. Provides full and complete Identification, definition, and description of topic,

background & why topic was chosen

Why The Topic Was Chosen

Look at assignment instructions for suggestions on choosing the topic. What made you choose this topic in the first place?

How The Topic Impacts Nursing Practice

Please show how your topic impacts nursing practice and/or patient care

How will the topic impact your role as a nurse in the nursing workforce or in the clinical setting?

Explain how the topic will impact your role as a nurse in nursing workforce or clinical setting.

Current Relevance

Provide a full description of your topic

Describe how your chosen topic is relevant/current to nursing practice

Explain what makes this topic relevant to nursing. Why should nurses care about this issue?

Current Relevance (Cont’d)

1. Provide a critical analysis supported by evidence based practice that is credible and timely (i.e. data, graph, research, statistics).

Clinical Practice Integration

How your topic is integrated and used in clinical practice

Explain how the topic will be integrated and used in clinical practice

Plan for Lobbying

1. Describe in detail what and how you would lobby your legislators or local government for funding to support your topic. 

(will you write a letter, social media, etc. include main points you will present to  persuade funding) 

2. What current or proposed legislation already exists that pertains to your topic?

Describe your plan on how you would lobby your legislators or local government for funding and support for your chosen issue/trend.

Plan for Lobbying (Cont’d)

Make insightful, clear and accurate connections to importance of

lobbying legislators & government

Conclusion

Show insight and comprehensive solutions/conclusions regarding your chosen topic

Summarize the key points

References

Remember to:

Include at least 4-5 research articles (Use WCU Online Library)

References need to be within the last 5 years

Do not include: blogs, chats, other universities, Wikipedia

Follow APA style

Include minimum 4-5 peer reviewed research articles as references in the presentation.

All articles must be within 5 years from today’s date.

No blog, chat, wikipedia, or other university information is allowed in presentation.

Directions for Submitting your Powerpoint

Open your PPT and go to “file” in top left corner.

Click “print” option. Make sure “print all slides” and “print slides with notes” is selected.

Go to “Save As” on the left hand side and be sure you save as a PDF.

Under your save as selection, click “more options”. Select the “Options” button and click the “Publish What” pull-down and then select “Notes Pages.” (If you click slides it will not show the speaker notes)

Click “OK.”

Complete your selection process by checking “Open file after publishing” and selecting the “Optimize for: ‘Standard’ and ‘Minimum Size’” choices.

Click on “Save” next to the “Tools” button at the bottom of the box.

CUIDADO É FUNDAMENTAL
UNIVERSIDADE FEDERAL DO ESTADO DO RIO DE JANEIRO . ESCOLA DE ENFERMAGEM ALFREDO PINTO

R E V I S T A O N L I N E D E P E S Q U I S A

INTEGRATIVE REVIEW OF THE LITERATURE DOI: 10.9789/2175-5361.rpcfo.v12.9103

DOI: 10.9789/2175-5361.rpcfo.v12.9103 | Souza JSR, Costa ACB, Vilela SC | Interpersonal relations between nursing-patient in the perspective…

CUIDADO É FUNDAMENTAL
UNIVERSIDADE FEDERAL DO ESTADO DO RIO DE JANEIRO . ESCOLA DE ENFERMAGEM ALFREDO PINTO

R E V I S T A O N L I N E D E P E S Q U I S A

R. pesq.: cuid. fundam. online 2020 jan/dez 12: 648-653 648

INTERPERSONAL RELATIONS BETWEEN NURSING-PATIENT
IN THE PERSPECTIVE OF CURRENT VIOLENCE

Relações interpessoais entre enfermeiro-paciente na perspectiva da
violência atual

Relaciones interpersonales entre enfermero-paciente en la perspectiva de
la violencia actual

Jhuliano Silva Ramos de Souza1, Andreia Cristina Barbosa Costa2, Sueli de Carvalho Vilela3

How to cite this article:
Souza JSR, Costa ACB, Vilela SC. Interpersonal relations between nursing-patient in the perspective of current
violence. Rev Fun Care Online. 2020 jan/dez; 12:648-653. DOI: http://dx.doi.org/0.9789/2175-5361.rpcfo.
v12.9103.

ABSTRACT
Objective: to re!ect on the importance of the interpersonal relationship between nurse-patient in the
perspective of current violence. Methods: this is a descriptive-re!ective study. “e databases used were:
Latin American and Caribbean Health Sciences Literature, National Library of Medicine, SCOPUS, Web Of
Science and Cumulative Index to Nursing and Allied Health Literature, in the languages: English, Spanish
and Portuguese, of the last ten years. Results: three categories emerged: 1) Violence su#ered by nursing
professionals in the workplace; 2) Education as a tool to minimize workplace violence and 3) Nursing care for
vulnerable people exposed to violence. Conclusion: interpersonal relationships can prevent acts of violence
from being carried out in the workplace, and the institution itself and the management sectors can train the
entire team, using continuing education as an e#ective tool for this issue.
Keywords: Interpersonal relations; Nurse-patient relations; Communication; Violence.

RESUMO
Objetivo: re!etir sobre a importância da relação interpessoal entre enfermeiro-paciente na perspectiva da violência atual. Métodos:
trata-se de um estudo descritivo-re!exivo. As bases de dados utilizadas foram: Literatura Latino-Americana e do Caribe em Ciências da
Saúde, National Library of Medicine, SCOPUS, Web Of Science e Cumulative Index to Nursing and Allied Health Literature, nos idiomas:
inglês, espanhol e português, dos últimos dez anos. Resultados: emergiram três categorias: 1) A violência sofrida pelos pro$ssionais
da enfermagem no ambiente de trabalho; 2) A educação como ferramenta para minimizar a violência no trabalho e a 3) Cuidado de
enfermagem a pessoas vulneráveis e expostas a violência. Conclusão: as relações interpessoais podem evitar que atos de violência sejam

1 Enfermeiro, Mestrando em Enfermagem do Programa de Pós-Graduação em Enfermagem da Universidade Federal de Alfenas –
UNIFAL-MG. Alfenas. Minas Gerais.

2 Doutora em Ciências. Professora da Escola de Enfermagem da Universidade Federal de Alfenas – UNIFA-MG. Alfenas. Minas Gerais.
3 Doutora em Ciências. Professora Adjunta da Escola de Enfermagem da Universidade Federal de Alfenas-UNIFAL-MG. Alfenas.

Minas Gerais. Brasil.

DOI: 10.9789/2175-5361.rpcfo.v12.9103
Interpersonal relations between nursing-patient in the perspective…

ISSN 2175-5361
Souza JSR, Costa ACB, Vilela SC

649R. pesq.: cuid. fundam. online 2020 jan/dez 12: 648-653

praticados no ambiente de trabalho, cabendo a própria instituição e os
setores gerenciais capacitarem toda a equipe, utilizando a educação
continuada como uma ferramenta e$caz para essa questão.
Descritores: Relações interpessoais; Relações enfermeiro-paciente;
Comunicação; Violência.

RESUMÉN
Objetivo: re!exionar sobre la importancia de la relación interpersonal entre
enfermero-paciente en la perspectiva de la violencia actual. Métodos: este
es un estudio descriptivo-re!exivo. Las bases de datos utilizadas fueron:
Literatura de Ciencias de la Salud de América Latina y el Caribe, Biblioteca
Nacional de Medicina, SCOPUS, Web of Science e índice acumulativo de
enfermería y literatura de salud aliada, en los idiomas: inglés, español y
portugués, de los últimos diez años. Resultados: surgieron tres categorías:
1) Violencia sufrida por profesionales de enfermería en el lugar de trabajo;
2) La educación como herramienta para minimizar la violencia en el
lugar de trabajo y 3) Atención de enfermería para personas vulnerables
expuestas a la violencia. Conclusión: las relaciones interpersonales
pueden evitar que se lleven a cabo actos de violencia en el lugar de trabajo,
y la propia institución y los sectores de gestión pueden capacitar a todo
el equipo, utilizando la educación continua como una herramienta e$caz
para este problema.
Descriptores: Relaciones interpersonales; Relaciones enfermero-paciente;
La Comunicación; Violencia.

INTRODUCTION
“e nursing profession is situated in teamwork, which

is con$gured in a collective aspect. For it to be practiced
competently, it is necessary to have a good interpersonal
relationship between the groups and an understanding
of the elements that permeate the contact with the team.
One of these elements is the communication process, which,
when done e%ciently, can bene$t the patient and others
involved, avoiding possible con!icts that may harm the
care provided, such as the loss of important information
for treatment and rehabilitation.1

In this sense, nursing care is characterized by the
interaction or dialogical relationship that is built with the other,
and is therefore considered as a primordial factor. “erefore,
it is essential to develop the potential of professionals for an
interpersonal relationship centered on both the biological
character and social and emotional relationships through
therapeutic listening and communication process.1

Regarding the work environment, nursing professionals
experience very delicate situations, among which are
the violence practiced by patients, family members and
colleagues, and can thus be identi$ed as moral, physical,
verbal, psychological, sexual and sexual violence. institutional
However, it is added that nurses have various duties in their
$eld of work, ranging from care to managerial functions,
which makes them more exposed to various types of violence.2

It is worth noting that the very nature of the activity made
him vulnerable to situations of violence at work, since they
work in multidisciplinary teams with rigid organization and
under constant pressure, thus experiencing daily con!icts
arising from interpersonal relationships with patients, family

members, colleagues and other health professionals.3 Violence
can negatively a#ect the lives of these professionals, causing
discomfort, fear and fear in the workplace, which can cause
dissatisfaction with it, as well as psychic changes through
syndromes, pain crises and health alterations in general.2
“ey conclude that it is urgent to create institutional policies
that protect professionals against all types of violence and
o#er a safe environment to perform their activities in a
digni$ed, respectful and ethical manner.

According to the World Health Organization4,5 violence
is a global public health problem, being among the leading
causes of death for men, women, children and the elderly who
su#er sexual, physical and psychological abuse, among others.
However, WHO states that these e#ects can be prevented
through public policies and preventive actions, in which most
violent attacks occur because of behavioral, social, economic,
political and cultural factors that could be modi$ed.

Health professionals who are most a#ected by violence
in the institutions in which they provide their services are
those of nursing, and it is necessary to develop strategies
for improvement in the workplace, with support from the
governmental spheres, the class councils themselves, with
to raise awareness about the importance of reporting,
implementing prevention and education policies so that
these professionals can improve the relationship between
colleagues and patients.6

Violence at work is understood as any voluntary action
between individuals or groups that can cause physical or
psychological harm arising in the workplace, or involving
institutional and organizational relationships or work-related
activities. “ese can be caused in labor relations, work
organization, working conditions, resistance, delinquency
and symbolic violence.7 It is noteworthy that the main
violence that the nursing professional su#ers in the hospital,
especially in the sector of urgency and emergency, are verbal
violence and bullying, in which negative factors are related
to the lack of information to the patient and authoritarian
professional attitude, which can generate con!icts regarding
the delay of care and even of the professionals themselves.
with their peers.6

“e rigid structure of the hospital environment,
the predominance of vertical hierarchical relationships, the
understatement of personnel, the precariousness of materials,
an exhausting shi& work rate and the multiple cognitive
and emotional demands, result in increased professional
vulnerability to the phenomenon of violence.’

In this sense, protective and managerial measures should
be implemented through proactive strategies to include
the theme of violence in improving patient care, without
undermining the team’s ethical-moral rights to contain or
prevent it.8 In this case, it is urgent to create institutional
policies that protect professionals against all types of violence,
and to o#er a safe environment so that they can perform
their activities in a digni$ed, respectful and ethical manner.2

Given the above, this study is justi$ed in the context of
nursing work, since it is expected to awaken the importance

DOI: 10.9789/2175-5361.rpcfo.v12.9103
Interpersonal relations between nursing-patient in the perspective…

ISSN 2175-5361
Souza JSR, Costa ACB, Vilela SC

650R. pesq.: cuid. fundam. online 2020 jan/dez 12: 648-653

of interpersonal relationships, joining communication
processes, therapeutic listening and nurse/patient
interaction, allowing care to be appropriate and quali$ed
in the development of e#ective and e#ective therapeutic
plans in the scenario of violence and $nally, to be able to
contribute scienti$cally, in the construction of a re!exive
practice that allows thinking concepts and actions that
involve interpersonal relationships in the scenario of violence
in the nursing context. Considering that it is through the
interpersonal relationship that the care process takes place,
this study aims to re!ect on the importance of the nurse-
patient interpersonal relationship in the perspective of
current violence.

METHODS
“is is a descriptive-re!ective article based on the

international and national literature on the theme of
interpersonal relations between nurse-patient in the
perspective of current violence. For this, articles were
searched in the databases of the Virtual Health Library
Brazil (VHL) and the Portal of Journals of the Coordination
of Higher Education Personnel Improvement (CAPES):
Latin American and Caribbean Health Sciences Literature
(LILACS). ), National Library of Medicine (PUBMED),
SCOPUS (Elsevier), Web Of Science (WoS), and Cumulative
Index to Nursing and Allied Health Literature (CINAHL).
“e Health Sciences Descriptors (DeCS) and the Medical
Subject Headings of the U.S. National Library of Medicine
(MeSH) were used, along with controlled and uncontrolled
descriptors: Interpersonal Relations; Nurse-Patient Relations;
Communication; Violence and “erapeutic Listening.
Followed by the operator booling “AND” for their intersection;
in the English, Spanish and Portuguese languages, with a time
frame in the last ten years (2008-2018). Ten articles were
selected for re!ective discussion and presented in categories.

RESULTS AND DISCUSSION
From the study emerged three thematic categories

for re!ective discussion: 1) Violence su#ered by nursing
professionals in the workplace; 2) Education as a tool to
minimize workplace violence and 3) Nursing care for
vulnerable people exposed to violence.

Violence suffered by nursing professionals in
the workplace

In this theme, it is possible to argue the violence that
nursing professionals su#er at work, especially in the
hospital environment, and highlight the typologies, health
consequences of these professionals and preventive strategies
in order to promote a better relationship between nurse-patient
and coworkers. In addition, it addresses the characteristics
of the aggressors’ pro$le and the lack of preparation and
information on the identi$cation of cases of violence among
nursing professionals.

Violence at work triggers risks for the development
of occupational injuries in health professionals, as well as
occupational diseases, lack of communication between
professionals, demotivation at work, con!icts, among others.9

Recently, the term horizontal violence has been used, which
means the behavior of peers who have the same social position
in a hierarchical institution, having a negative impact on job
satisfaction and the relationship between hospital nurses.
In this context, horizontal violence has been pointed as a source
of dissatisfaction, demotivation, problems among co-workers
and extreme overload, causing in these professionals the
development of stress and recurrent illnesses at work.10

“e nurses who work in the hospital are exposed to
violence at all times, and screening is the sector with the highest
propensity for occurrences of this act, usually associated with
the person, which involves stress, feelings of helplessness, male
gender, age group between 20 and 30 and abuse of alcohol
and other substances.11 O&en acts of violence are associated
with insu%cient sta%ng, excessive patient waiting time, poor
safety and overcrowding. In addition, professional inexperience
is considered a negative factor in which lack of empathy,
intolerance, and judgment can a#ect communication and
attitude toward patients and their families.11

When it comes to communication in the workplace, when
not properly performed can bring consequences that trigger
acts of violence to professionals. In addition, it is up to the
institutional bodies to question the possible causes that lead to
changes in patients’ behavior and adopt preventive measures,
as well as the creation of speci$c protocols to prevent acts
such as this from harming the physical and psychological
health of professionals.

“e emergency room is another environment very
susceptible to acts of aggression with nurses, and the factors
that induce this violence are related to the needs of unmet
patients, such as delayed care and unsatisfactory responses,
which cause con!icts when providing care. For these episodes
to be avoided or minimized, it is necessary to use preventive
strategies, as well as interpersonal relationships, health
education as e#ective forms of care and preparedness to cope
with situations of violence in health services.12

Understanding this phenomenon helps nurses to
understand that violence is present in the hospital
environment, and that there are tools that help improve care
and interpersonal/interprofessional relationships, as well
as the use of listening, paraphrasing and communication
techniques (verbal and nonverbal) can be used to establish
or reestablish communication and con$dence, preventing
and minimizing situations of violence and modifying the
nursing care scenario for the patient.13

On the other hand, relational factors, lack of
communication, and sta# attitude towards patients and family
members also increase the incidence of violent behavior.
In this context, it is observed that interpersonal relationships
and communication are present both in the sense of being
intervention strategies and as preceptors in situations of
violent behavior.

DOI: 10.9789/2175-5361.rpcfo.v12.9103
Interpersonal relations between nursing-patient in the perspective…

ISSN 2175-5361
Souza JSR, Costa ACB, Vilela SC

651R. pesq.: cuid. fundam. online 2020 jan/dez 12: 648-653

Education as a tool to minimize workplace
violence

In this category we re!ect on the importance of education
as a tool to promote, reduce and identify violence in the
workplace of nursing professionals.

“e National Policy on Permanent Health Education
(PNEPS), implemented in 2004 by the Ministry of Health,
aims to stimulate and meet the demand regarding the
professional quali$cation of health workers.14 According to
this policy, quali$cation is one of the main ways to prepare
them to face di%culties in health services. In this sense,
PE is recognized as learning at work, in which learning and
teaching are incorporated into the daily life of institutional
organizations based on meaningful learning and the
possibility of transforming professional practices.

As with PE, Health Education is an educational process of
knowledge construction in health that aims at the thematic
appropriation by the population, created by the Ministry of
Education, is a set of practices in which contribute to the
increase of the autonomy of people in their own health care,
in the debate with professionals and managers, in order to
achieve health care according to their needs.14, 15, 16

“us, the Health Education and PE process are strategies
for democratizing the asymmetrical relations of power and
decision, increasing access to information and involvement
with work con$gured in collective spaces in the development
of competences and skills.17

However, these tools came to improve, recycle and
improve the relationship in the provision of care, in this
case, in situations of violence at work, having possibilities
to modify this reality. In addition, as regards professional
skills and competences, they should also be directly linked
to the patient’s general needs, which should be heard and
respected, thus ensuring a good nurse / patient relationship.18

It is important to have a satisfactory approach with
the use of instruments that facilitate the identi$cation and
recognition of victims of violence. “erefore, it is not enough
just to recognize them, it is necessary to train professionals
so that they can o#er safe care in a welcoming environment,
providing security so that victims have the opportunity to
talk about it without any fear and fear.19

Although nursing science respects human rights and
acts to minimize the individual’s biopsychosocial su#ering,
failures in the care of this population are still evident, which
indicates lack of knowledge and training regarding the
referral, identi$cation and compulsory noti$cation of cases
of violence. “e nursing sta# must adopt welcoming, safe
and private behaviors so that this scenario can be modi$ed.20

In this context, it is important to awaken to the managers
who work in the institutions, the relevance of the use of
educational tools as a guide to these professionals, so that
there is commitment from the administrative sector, in order
to enable them in legislative issues, in the care approach and
identifying clinical signs of violence and their social and
judicial precepts. It also encourages nursing professionals to

seek such skills, as it enables greater security in performing
actions, minimizing the consequences that violence causes
to victims, such as negative and traumatic feelings.20

“erefore, Health Education and PE are important
during health promotion activities in situations of violence,
favoring possibilities for e#ective nursing practice, expanding
concepts, competencies and skills of professionals, as well
as of the assisted population.19

It is necessary for professionals to be aware that there
are educational and managerial strategies that help them in
making decisions and changes related to care and approach,
so that they collectively and individually favor them in
relation to eventual cases involving violence in the workplace
perpetrated by the patients themselves, as well as their families
and co-workers.

Nursing care for vulnerable people exposed
to violence

Finally, this category addresses the role of nurses as a
basic professional in helping people in situations of risk and
vulnerability, including young students, women and people
in situations of self-in!icted violence.21,22,23 “rough listening
and welcoming, nurses who work in support groups work with
prevention, promotion, protection and guidance strategies
in relation to cases of violence in di#erent scenarios.

It is worth mentioning that nurses perform various
care functions. One of them is to o#er therapeutic support
focused on health promotion, prevention and rehabilitation
focused on emotional problems, such as the use of support
groups in schools, applying listening, respect, empathy and
welcoming skills.21

“ese groups may be led by nurses, speci$cally mental
health nurses, who will develop collective activities in
which students will share their traumatic experiences, share
experiences and concerns, promoting better coping with these
situations. Focusing on primary prevention in school settings,
with minimization of cases such as bullying, dating violence,
trauma sequelae, and diagnosable mental disorders.21

Many people recognize the work of nurses as being
performed exclusively in the hospital sector, linked to care
and technical functions, while many are unaware of the
quali$cation of this professional to answer questions related
to the patient’s emotional aspect, since the service will not
always have the presence of a professional psychologist.
For this reason, it is of great relevance that the nurse is aware
of when to use the appropriate therapeutic techniques and
if they are having satisfactory results, including regarding
the professional and personal satisfaction of the nurse
in the face of various situations of vulnerability, in particular,
the situations of violence.

When approaching a vulnerable person, professionals
should be able to o#er comprehensive and quality care,
providing an image of trust and welcome, attention and
empathy, thus establishing a greater bond with the victims.
However, many nursing professionals are resistant to acting

DOI: 10.9789/2175-5361.rpcfo.v12.9103
Interpersonal relations between nursing-patient in the perspective…

ISSN 2175-5361
Souza JSR, Costa ACB, Vilela SC

652R. pesq.: cuid. fundam. online 2020 jan/dez 12: 648-653

against victims of violence, $nding it very di%cult to approach
and identify, arousing reactions of fear, unpreparedness and
insecurity in caring for the victim.22

Professional incapacity causes feelings and negative
reactions to the nurse, causing frustration to become a
problem in patient care. “us, it is necessary to re!ect on
vocational training as a strategy to solve problems involving
victims of violence and their aggressors, thus improving the
interpersonal relationship to victims of violence.

It is known that nurses are present in various situations
of vulnerability, including suicide. Being a type of self-
in!icted violence, it is up to the professional to develop
strategies that help people involved in this su#ering. One
very e#ective and widely used strategy is therapeutic listening.
“erapeutic listening can avoid possible episodes of suicide
attempt, because its technique allows the professional to
o#er individualized assistance to those in psychological and
emotional distress, using communication, understanding and
understanding with the person who lives this process, thus
providing assistance, protection and quali$ed guidance.23

“us, it is appropriate to point out that nursing care
can unfold into group and individual activities, which are
developed by light technologies as successful strategies. “ese
are focused on the human relations of care, such as welcoming,
relationship / interaction and communication, that is, they
are technologies whose focus is between the worker and the
user, in the production of their relationships.24

FINAL CONSIDERATIONS
It is observed that interpersonal relationship and

communication are present both as intervention strategies
and as preceptors in situations of violent behavior. “ese
situations are evident in the nursing profession as pointed
out, both in the fact of su#ering di#erent types of violence
and in the narrow sense of caring for people in this condition.
Given this, it is believed that nurses should be able to face
and take care of victims and perpetrators, knowing how to
preserve themselves physically and emotionally.

“erapeutic practices, especially therapeutic listening, have
shown to be positively e#ective as a means of prevention and
welcoming in situations of vulnerability and violence, as well
as e#ectively favoring autonomy, empathy and understanding
in the interpersonal relationships between nurse-patient about
external causes and internal recurrent violence.

Health educational tools should be strategies present
in nursing work, since it enables the professional and the
user of health services to broaden the $elds of action and
enable greater e#ectiveness in situations of violence in their
professional practice.

We list as a limitation of the study the selection of material,
considering that, as it is an evident theme in the profession,
few studies are dedicated to this theme. Future studies on
the e#ectiveness of interpersonal relationships between the
interdisciplinary team itself, and the relationship with other
$elds of activity, such as primary health care, maternal and
child health and elderly health are suggested, since studies

addressing thematic in the hospital environment. Nor have
studies been identi$ed that point to institutional, political
and social practices that will assist such professionals in an
e#ective relational approach.

“e study contributes to the knowledge about the
dialectic of interpersonal relationships in situations of
violence since it can be predisposing to situations of violence
as a protective factor.

ACKNOWLEDGEMENT
“is work was carried out with the support of the Higher

Education Personnel Improvement Coordination (CAPES)
– Financing Code 001.

We are grateful to the Health Technologies, Innovations
and Sustainability Research Group (GPTISS).

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org/10.5935/1414-8145.20150062.

2. Lima MP, Oliveira J, Musse S. Violência sofrida pelos enfermeiros nas
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Received in: 22/10/2019
Required revisions: Did not have

Approved in: 22/10/2019
Published in: 01/06/2020

Corresponding author
Jhuliano Silva Ramos de Souza

Address: Rua da Liberdade, 72, Vila Betânia
Alfenas/MG, Brazil

Zip code: 37137-090
E-mail address: [email protected]

Telephone number: +55 (35) 99129-9524

Disclosure: The authors claim
to have no conflict of interest.

© 2020. This work is published under
https://creativecommons.org/licenses/by-nc-nd/(the “License”).

Notwithstanding the ProQuest Terms and Conditions, you may use this
content in accordance with the terms of the License.

Nephrology Nursing Journal May-June 2021 Vol. 48, No. 3 261

We live in a tumultuous time with many competing
demands, and COVID-19 has only heightened our emo-
tional, physical, and financial stress. These immense stres-
sors affect our emotional and behavioral responses, mak-
ing it difficult to always ‘be our best self.’ As health care
professionals who provide a life-sustaining therapy in the
form of kidney replacement therapy (KRT) like hemodial-
ysis, we like to think of ourselves as just that – ‘profession-
al.’ However, we can all get pulled in many directions
whether it be at home or at work, and authentically, we do
not always show up as the best version of our self. At the
heart of being able to identify patterns of behavior that
‘creep in’ or ‘explode out’ and are not aligned to being our
best self is the concept of learning emotional intelligence.
Researchers, psychologists, and sociologists have described
the emotionally intelligent person as having the insight into
one’s behavior and then being able to manage that behav-
ior. Emotional intelligence is needed now more than ever
in the clinical setting of nephrology. This article provides
an overview of the concept of emotional intelligence, a
brief overview of the brain science behind behavioral pat-
terns, and why it is valuable to enhance skills in emotional
intelligence. Practical tools will be highlighted for nephrol-
ogy nurses to optimize bringing their best self to work dur-
ing these challenging times.

Copyright 2021 American Nephrology Nurses Association.
Lawrence, J.A., & Parkes, R. (2021). How do you be your best

self in a vexatious world? Nephrology Nursing Journal,
48(3), 261-265. https://doi.org/10.37526/1526-744X.
2021.48.3.261

How do we survive, let alone thrive, in health care? The
complexity of providing care to patients and families on
chronic kidney replacement therapy can be taxing for the
most expert and resilient of health care professionals.
Further complicating this by a global pandemic can pro-
duce feelings of frustration and anxiety that can reduce our
effectiveness in the everyday, yet we are compelled to prac-
tice competently and professionally. Working on oneself is
key to optimizing one’s resilience during volatile, uncertain,
complex, and ambiguous times. This article introduces the
concept of emotional intelligence and provides a brief
review of the brain science behind behavioral patterns,
highlighting how all health care professionals can engage in
self-work to bring our best selves to the every day.

Key Words:
Emotional intelligence, self-management, insight, managing
emotions, brain science, hemodialysis, stress.

How Do You Be Your Best Self in a Vexatious World?
Julie Ann Lawrence, MScN, RN(EC), CNeph(C), and Rebecca Parkes, BA

1.1 contact hours

N e P H r o l o g y N u r s I N g J o u r N a l

Health care is a high-stress, high-change environment
on any given day. When you add in COVID 19 and the
implications of a worldwide pandemic, it is no surprise that
the stress on care providers has increased exponentially.
COVID-19 has thrust us all into uncharted territory. It has
stressed an already stressed workplace. For health care pro-
fessionals, burnout is compounded, the risk of vicarious
trauma has been magnified, and the additional burden of

Julie Ann Lawrence, MScN, RN(EC), CNeph(C), is a Nurse Practitioner,
Kidney Care Centre, London Health Sciences Centre, London, Ontario,
Canada.
Rebecca Parkes, BA, is a Consultant, Life Coach, St. Thomas, Ontario,
Canada.
Acknowledgment: As the primary author, I would like to acknowledge
the foundational work of Lianne Collins and Rebecca Parkes in develop-
ing an Emotional Intelligence Strategy and experiential Emotional
Intelligence workshop in 2018 for staff and leaders at London Health
Sciences Centre.
Statement of Disclosure: The authors reported no actual or potential
conflict of interest in relation to this nursing continuing professional
development (NCPD) activity.

Instructions for NCPD Contact Hours
NNJ 2118

Nursing continuing professional development (NCPD) contact
hours can be earned for completing the learning activity
associated with this article. Instructions are available at

annanurse.org/library
Deadline for submission: June 30, 2023

Nephrology Nursing Journal May-June 2021 Vol. 48, No. 3262

How Do You Be Your Best Self in a Vexatious World?

exposing ourselves to a life-threatening virus and potential-
ly taking it home to our family has become a new tipping
point.

The current health care arena can be described as a
VUCA world: Volatile, Uncertain, Complex and
Ambiguous. The concept of VUCA was first used by the
U.S. Army War College in the 1980s to describe the chang-
ing landscape after the Cold War (U.S. Army Heritage and
Education Center, 2018). Who would have guessed at that
time the terminology would move from the combat field
into the boardroom and eventually health care (Gallo,
2010)? Volatile is unstable, unpredictable, and explosive.
Uncertainty refers to lack of concrete trends or patterns
that informs or allows prediction for the future.
Complexity refers to interconnected parts that become
more dynamic and/or increasingly unknown, thereby lim-
iting past predictive outcomes as a framework for new
changes. Ambiguity is about the present and turbid clarity
for the future. The environment is unfamiliar and foreign
to current expertise. Now let’s look at the VUCA world in
the context of clinical environment.
• Volatile: The vector of transmission and confounding

factors seemed to change daily in terms of what experts
viewed as the means of infectability. At the beginning
of the pandemic, opinion and evidence, along with
instant messaging that was (or was not) evidence-based,
brought about a rapidly changing and unpredictable
clinical environment. Vectors of transmission (droplet,
aerosol, fomite-mediated) were all documented at one
point as being contributory.

• Uncertain: Look at how difficult it was to predict in the
early stages how COVID-19 would evolve or unfold.
As such, it was difficult to use past issues or learnings to
predict future outcomes. For example, did you experi-
ence arriving to your shift to have a patient assignment,
then a cardiopulmonary arrest situation arises, and you
are pulled to jump in and start resuscitation efforts, yet
the process is to don personal protective equipment
(PPE) according to procedure (as precious minutes pass
by) until you are able to begin invasive or aggressive
life sustaining measures? Couple this with the ongoing
threat of inadequate PPE, and you can see and feel the
uncertainty.

• Complex: What about the cohorting of patients to an
area of isolation? How did your unit accomplish this?
In hemodialysis units with close congregation of
patients, were patients shuffled on entry to the unit if
presenting with symptoms? Were patients in long-term
care or residential/group living cohorted? Decisions
and strategizing regarding the transportation of large
groups, dialyzing in close quarters while also attending
to your local health department standards, and mesh-
ing them with your own facility standards makes navi-
gating this daily quite a complex environment. The
downstream implication is the minute-to-minute shift-
ing of patient assignments and the chair position within
the hemodialysis unit.

• Ambiguous: Recall the initial confusion regarding
early information of vector transmission, availability of
PPE, COVID-19 testing/treatment options, and/or
determination of best practices that changed numerous
times in a day. This challenged nurses, charge nurses,
and nephrology teams to stay current to the realities of
risk in a period that was turbid in clarity.

You can no doubt identify the impact this VUCA world

has had on your ability to bring the best version of yourself
to each and every day. How do you manage when you are
pulled in many directions at work and you have to spin on
a dime? What is your reaction or ability to stay calm and
optimistic when you show up for your shift, knowing you
might be short-staffed or on a shift with a colleague who is
constantly complaining?

When you feel exhausted, depleted, and unappreciat-
ed, what is your mindset when you are driving home and
someone pulls out in front of your car? Do you ever find
yourself feeling sharp and impatient with the ones you
love, only to climb into bed at night realizing in hindsight
that you over-reacted in a number of situations? During the
pandemic, have you noticed your feelings of anxiety and
fear growing?

How do we begin to cope in this ever-changing land-
scape and find a place of homeostasis, let alone bring our
best self to each and every day? What we know is that
because we are living in a VUCA world, it is unlikely we
will go back to a slower, predictable, easier pace.
Therefore, we are challenged to respond and adapt to this
new normal and the next new normal each as ‘new nor-
mal’ evolves and arrives.

We are moving through a world of problems that
demand speed, deep thinking, and tolerance of unknowns
to solve to a new reality that requires patience, sense-mak-
ing, and an engagement despite uncertainty and ambiguity.
If we are unable to control the world at large, the only
piece we can control or manage is our inner world.
Although not a quick fix, the good news is, it is possible.

The key to thriving versus barely surviving is found in
the work we do on ourselves. If we build and enhance our
self-awareness and self-management skills, we are more
likely to be confident, an effective communicator, and
resilient (Mayer et al., 2004). These skills are often consid-
ered part of the cluster of skills known as emotional intelli-
gence. A review of the literature searching emotional intel-
ligence and nursing revealed a paucity of information with-
in the context of providing direct patient care. There are
certainly more numerous sources and studies found in the
context of nursing leadership. Prezerakos (2018) reviewed
qualitative and quantitative studies concerning the emo-
tional intelligence of nurse leaders and the evidence-based
composition of their results on the impact of job satisfac-
tion and leadership effectiveness. The literature is rich in
emotional intelligence as a key factor in optimizing or cor-
relating with transformational leadership (nursing and non-
nursing organizational outcomes). Notably, a smaller num-

Nephrology Nursing Journal May-June 2021 Vol. 48, No. 3 263

ber of articles referenced the emotional impact of kidney
patients because of providers’ abilities to show empathy
and communication linked to emotional intelligence as an
important area for further study in the nephrologist popu-
lation (O’Hare et al., 2018), but these did not focus on the
development of emotional intelligence in this context.
Hence, there is a paucity of literature related to the
nephrology nurse and emotional intelligence. One article
discussed the impact of emotional intelligence on educa-
tion programs in hemodialysis. In this article, it was noted
that renal nurses had improvement in quality of life when
emotional intelligence was included in their education pro-
gram for learning the skill of hemodialysis (Shahnavazi et
al., 2019). As such, it is valuable to have discussions on how
emotional intelligence can enhance our own personal
development, while as nurses in nephrology, we can also
increase our professional development.

Overcoming limitations of your beliefs so you are calm
and composed versus fearful and anxious, and bouncing
back more easily from unexpected changes or challenging
situations are some of the benefits of developing our emo-
tional intelligence. Emotional intelligence is needed now
more than ever in the clinical setting of nephrology
because there has been evidence of employees with higher
emotional intelligence having high job satisfaction and
higher organizational commitment. A meta-analysis of
emotional intelligence and work attitudes by Miao and col-
leagues (2017) found that emotional intelligence improved
job satisfaction by reducing negative feelings, increasing
positive feelings, and/or improving job performance.
Hence, particularly during the VUCA world of a pandem-
ic, why wouldn’t we want to cultivate these performance
and work rewards?

Emotional Intelligence – What Is It Really?

There are many interpretations, definitions, and myths
about emotional intelligence. Some people think having
emotional intelligence is about being nice or giving full
reign to your feelings or anything that is ‘warm fuzzy,
touchy feely.’ It is often referred to as a ‘soft skill.’ Some
people don’t even consider developing a new skill set
because they erroneously think, “This is just the way I am!”
Emotional intelligence is well researched and is a specific
skill set that is the key differentiator between being average
or not coping with life, and being a star performer and
more resilient (McClelland, 1998).

One pioneer who studies the concept of emotional
intelligence is Dan Goleman. Although there are many
definitions of emotional intelligence, on a basic level, his
working definition is simple, practical, and easy to under-
stand, and can be applied to your personal and profession-
al life. Emotional intelligence is the ability to recognize and
understand your emotions and the emotions of others, and
to use this awareness to effectively manage yourself and
your relationship with others (Goleman, 2004).

The concept of emotional intelligence emphasizes two
components. The first is having awareness, insight, and

understanding of one’s own emotions (and the emotions of
others). If you understand the emotional background and
foreground, this is the basis that leads to the second
process, which is moving toward understanding one’s
responses and behaviors. Therefore, the patterns of behav-
ior can be managed in a more adaptive manner. By no
means does this imply the making of an emotional intelli-
gent person is two-dimensional and linear process. Deeply
embedded in gaining awareness and insight into one’s
emotions requires that you understand how each emotion
was borne, harvested, manifested, reinforced, or dissuaded
in our formative years.

During the pandemic, there are feelings of anxiety, fear,
and uncertainty. These emotions may stem from feeling a
lack of control in the current health environment. Further,
one’s safety as a health care provider is essentially reliable
upon the public maintaining their safety through social dis-
tancing and other techniques that reduce the risk of viral
transmission. For health care providers, nurses in particu-
lar, who are caring for those with illnesses, the current
health care arena can be more anxiety-provoking when
entering work every day. Having the ability to recognize
and manage one’s emotions, while also managing your
response to the emotions of others, is key to an adaptive,
calm, and constructive work environment, and ultimately,
to enhancing team effectiveness. Moreover, developing
this skill increases the likelihood that your resilience and
homeostasis (in and outside the work environment) will
optimize mental health. Who doesn’t want to optimize
emotional balance and mental health in a vexatious period
of health delivery history? To understand the concepts of
emotional intelligence, one must first understand how the
brain works. This is a starting point to understanding
behavior patterns and emotional responses.

Brain Science

What is fascinating is that the recent neuroscience
research is exploding, and it supports our understanding of
emotional intelligence. Everything we take in through our
senses passes through our amygdala, which is walnut-sized,
and in the center of the emotional center of the brain.
Everything passes through the amygdala before it gets to
the prefrontal cortex, the thinking part of the brain. This is
the part of your brain responsible for problem-solving,
decision-making, and rational thought, which is why it is
often referred to as the executive center of the brain.

The amygdala is hard-wired for survival. Nurses are
familiar with the concepts of fight, flight, or freeze. These
built-in reflex actions are why we have survived as a
species. When the amygdala gets activated, it takes over.
This neural hub does not differentiate between emotional
and physical threat. Humans continue to be on the earth
because we survived despite threats of physical harm, part-
ly due to responses of fight, flight, or freeze. Practically
speaking, these raw behaviors can be sourced to emotional
threats as well. When triggered emotionally, does your
amygdala knee-jerk to flight (withdraw, make excuses for

Nephrology Nursing Journal May-June 2021 Vol. 48, No. 3264

How Do You Be Your Best Self in a Vexatious World?

not attending highly emotionally charged meetings or par-
ticipating in contentious projects), fight (move into a per-
son’s space to confront, insist upon your way of doing
things, using power and control over others), or freeze
(making oneself small and unseen, quiet and passive in
actions, fence-sitting in opinions)? Situations in which these
responses (one or all) can be apparent in patterns of behav-
ior when we are triggered emotionally. In this manner, we
can refer to these reflexive responses as being taken
“hostage” by our emotions because there is very little (if
any) thinking involved. Rather, they are a very limbic, raw
behavior.

Thankfully, we do not operate in the everyday being
held hostage to our amygdala. The brain has multiple cog-
nitive centers that contravene and bring about rationale
thinking and behavior. One cognitive center is the pre-
frontal cortex, or the thinking area of the brain. This pro-
vides the day-to-day functioning in a non-threatening envi-
ronment. However, bring about a stressful or a highly
charged situation, and the prefrontal cortex goes offline as
the amygdala and its limbic responses take over, and in
essence, we can become hijacked toward emotional
responses that we would otherwise not exhibit.

Have you ever found yourself in a situation at work or
with a family member when you felt upset or felt strongly
about what you had to say because you believed you were
right? Then 30 minutes later, an hour later, two hours later
when you have calmed down, you say, “Oh my gosh, what
was I thinking?” From a brain science perspective, you
weren’t thinking. Your amygdala took over and prevented
you from accessing that thinking, rational part of your
brain. Think of it as being triggered, flooded, or hijacked.

It is important to understand that we do not just have a
hijacked moment when we are upset or angry. Have you
ever found yourself in a meeting or out with friends for din-
ner, when someone makes a comment that seems ridicu-
lous? You may be sitting quietly and outwardly smiling, but
inwardly thinking self-righteously, “I can’t believe she actu-
ally just said that!”? In these moments, we are often trig-
gered by patterns of behavior or belief. Perhaps more sub-
tle than an angry outburst, these inward thoughts/judg-
ments demonstrate an example of still not bringing our
best selves in those moments, either. The patterns are
“automatic” and seem to be driving us.

Take a moment to think of your own example when
you may have been hijacked or you have responded in a
manner that was not your best self, only to later feel regret
and ask yourself, “What was I thinking?” or “Why did I do
that?” Perhaps you acted out in an untoward manner (e.g.,
responded to a patient tersely/unprofessionally, became
weepy/angry during a meeting, responded in text or email
from a self-righteous stance, or vented loudly for the sake
of hearing your own voice in the lunch room). In these
examples, something triggered you, which opened the
flood gates for your amygdala to spill messy, emotional
responses that are not consistent with what your prefrontal
cortex would view as professional.

From a brain science perspective, it is known that emo-
tions are contagious (Hatfield, 1994). In particular, emo-
tions seen as threatening (anger, hostility, hatred, defen-
siveness, selfishness, jealousy, sarcasm, fear, or anxiety) can
evoke negative responses in those working with a person
exhibiting these. Becoming aware of one’s own triggers is
a key component of awareness because then one can alter
their own responses.

Often people will wonder how to bypass this emotional
part of the brain. The answer is simple – you can’t. The
goal of cultivating your emotional intelligence and becom-
ing more effective is to understand what triggers you so it
can be managed. Effective practice and contribution to a
health care team is about staying connected to what is a
trigger for ineffective and maladaptive behavior. More –
over, keeping the neuropathways open between our pre-
frontal cortex, and the amygdala is key in the development
of skill in emotional intelligence. In those moments, we can
bring all parts of our brain together to more effectively
respond to a problem or difficult situation.

To change a previous pattern is to take what is unconscious
and automatic and make it conscious. It is only in this place
you can choose something different for yourself. Again, the
good news is you can rewire your brain. You can create a new
“automatic” that is healthy, constructive, and different from
your current reactions and do so purposefully.

Rewiring Your Brain

Where attention goes, neural firing flows, and neural connection
grows. —Daniel J. Siegel (Siegel, 2010)

Are any of these statements familiar to you? “Oh this is

the way I am,” “I can’t change,” or “Everyone knows I’m
just loud, but I don’t really mean it.” Research shows you
can change with practice (Boyatzis, 2006). Here’s how
starting on the path of emotional intelligence development
can lead to change.

Developing skill in emotional intelligence is about peel-
ing away the layers of “that’s just me” to move to a place
of knowing ourselves, and replacing the ineffective behav-
iors and self-limiting beliefs with empowered ones. Think
of it as an archeological dig. It is uncovering the condition-
ing of your brain and amygdala through awareness. It does
not matter if you grew up in a loving, caring family with
both parents present or if you grew up with physical abuse
or alcoholism. We all have an amygdala that has been con-
ditioned by our early life experience. It is the result of neu-
ral networks being formed and reinforced through repeat-
ed use to the point where activation became automatic. We
learned most of our primal and survival patterns of behav-
ior when we were very young and reacting to what we per-
ceived as threatening. This does not have to equate to
physical threat, but also how, as young children, we tried
to stay safe, loved, and met with approval. What we
learned in our formative years impacts us for the rest of our
lives – in our workplaces, homes, and all our interactions

Nephrology Nursing Journal May-June 2021 Vol. 48, No. 3 265

in the world. Truly, to have entered into the nursing profes-
sion, much of what we learned was positive and served us
well to complete school and gain employment. Yet some
behaviors may be limiting our potential for success.
However, we can change what we learned in the past and
learn new and better ways of interacting with the world
around us. We can literally rewire our brains for success.

Taking Stock

The quest for cultivating emotional intelligence begins
with self and the deep dive within. Awareness is the first step
to change. Each day for the next week, watch and observe
yourself. Observe when you are triggered or feel reactive. Is
there a pattern to when that happens? Is it with a certain per-
son (someone you experience as bossy or in charge, some-
one who is quiet and passive, or someone who is sarcastic)?
Start to notice when you get reactive and notice what you
do in response to that? How do you react (fight, flight, or
freeze)? You do not have to change anything. Just pay atten-
tion and make what might have been automatic and uncon-
scious, and make it visible. What do you see?

The Conscious Leadership Group (2014) offers a tool
(illustrated in their YouTube video) that can help you
understand how you see the world and the manner in
which you react by determining your “location” – by
answering the question “Where am I?” They suggest that
you envision a line – a simple black line. Do you see your-
self as “above the line” – seeing things through a lens of
opportunity (an optimistic outlook – open, curious, com-
mitted to learning) or “below the line” – seeing things as a
problem (negatively/pessimistic outlook – defensive,
closed, committed to being right)? This tool can help a per-
son identify where their patterns of behavior are located
and then highlight behaviors the person may wish to focus
on to change. For example, activities that include blame,
denial, making excuses, waiting for others to act, finding
fault, seeing failure, judgment with defensiveness, feeling
no control, and seeing problems and obstacles are all exam-
ples of actions that are “below the line” of effectiveness. As
you observe your behavior in real time or reflect upon pre-
vious instances when you may not have been at your best,
ask yourself if your behavior was above the line or below
the line? Take this awareness forward when continuing to
be observant to how you operate day to day.

In Summary

In summary, we outlined the platform for understanding
the concept of emotional intelligence and brain science as a
foundation for understanding behavior patterns and emo-
tional responses, and discussed cultivating self-awareness
and emotional/cognitive resiliency with practical tools to
bring your best self in these challenging times. This is partic-
ularly relevant and current for the nephrology health care
professional when providing care to those in need. We are
relied upon to bring our best selves to work in the everyday

with the goal to provide safe and sensitive care to our clients
and families to optimize their health and wellness. When
caring for oneself, optimizing skill in emotional intelligence
would ultimately facilitate success for the nephrology nurse
to do so in a caring, yet consciously resilient manner.

References
Boyatzis, R.E. (2006). An overview of intentional change from a

complexity perspective. Journal of Management Development,
25(7), 607-623. https://doi.org/10.1108/02621710610678445

Conscious Leadership Group. (2014). Locating yourself – A key to con-
scious leadership [YouTube video]. https://www.youtube.
com/watch?v=fLqzYDZAqCI

Gallo, A. (2010). Making your strategy work on the front line.
Harvard Business Review. https://hbr.org/2010/06/making-
your-strategy-work-on-t

Goleman, D. (2004). What makes a leader? Harvard Business Review,
82(1), 82-91. https://hbr.org/2004/01/what-makes-a-leader

Hatfield, E., Cacioppo, J., & Rapson, R. (1994). Emotional contagion
(Studies in emotion and social interaction). Cambridge University
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Mayer, J.D., Salovey, P., & Caruso, D.R. (2004). Emotional intelli-
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https://doi.org/10.1111%2F1467-9280.00065

Miao, C., Humphrey, R.H., & Qian, S. (2017). A meta-analysis of
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https://doi.org/10.1111/joop.12167

O’Hare, A.M., Richards, C., Szarka, J., McFarland, LV., Showalter,
W., Vig, E.K., Sudore, R.L., Crowley, S.T., Trivedi, R. &
Taylor, J.S. (2018). Emotional impact of illness and care on
patients with advanced kidney disease. Clinical Journal of the
American Science of Nephrology, 13(7), 1022-1029. https://doi.
org/10.2215/CJN.14261217

Prezerakos P.E. (2018). Nurse managers’ emotional intelligence and
effective leadership: A review of the current evidence. The
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Instructions for NCPD Contact Hours
NNJ 2118

Nursing continuing professional development (NCPD) contact
hours can be earned for completing the learning activity
associated with this article. Instructions are available at

annanurse.org/library
Deadline for submission: June 30, 2023

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.

UC Irvine
Western Journal of Emergency Medicine: Integrating Emergency
Care with Population Health

Title
Unheard Victims: Multidisciplinary Incidence and Reporting of Violence in an Emergency

Department

Permalink
https://escholarship.org/uc/item/9001453s

Journal
Western Journal of Emergency Medicine: Integrating Emergency Care with Population

Health, 22(3)

ISSN
1936-900X

Authors
McGuire, Sarayna S.

Mullan, Aidan F.

Clements, Casey M.

Publication Date
2021

DOI
10.5811/westjem.2021.2.50046

License
https://creativecommons.org/licenses/by/4.0/ 4.0

Peer reviewed

eScholarship.org Powered by the California Digital Library

University of California

Western Journal of Emergency Medicine 702 Volume 22, no. 3: May 2021

Original research

Unheard Victims: Multidisciplinary Incidence and Reporting
of Violence in an Emergency Department

Sarayna S. McGuire, MD*
Aidan F. Mullan, MA†
Casey M. Clements, MD, PhD*

INTRODUCTION
Background

Workplace violence in healthcare is a serious threat to
staff. Between 2011–2013, the number of workplace assaults
averaged approximately 24,000 annually, with nearly 75%
occurring in healthcare settings. Data from the Bureau of Labor
Statistics show that incidents of serious workplace violence
were four times more common among healthcare workers than
those in private industry.1 Emergency departments (ED) and
psychiatric hospitals are two areas in healthcare where violence
is most commonly reported.

*Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
†Mayo Clinic, Department of Quantitative Health Sciences, Rochester, Minnesota

Introduction: Workplace violence in the emergency department (ED) is a serious threat to staff
and is likely to go unreported. We sought to identify the incidence of violence among staff at our
academic ED over a six-month period.

Methods: An anonymous survey was sent to all ED staff, asking whether respondents had
experienced verbal abuse or physical assault over the prior six months and whether they had
reported it. Those working in the department <6 months were excluded from analysis. We used chi-
squared comparison to analyze the results.

Results: We analyzed 242 responses. Overall, 208 (86%) respondents indicated being verbally
abused in the preceding six months, and 90 (37%) indicated being physically assaulted. Security
officers had the highest incidence of verbal abuse (98%), followed by nursing (95%), patient care
assistants (PCA) (90%) and clinicians (90%), phlebotomists (75%), care team assistants (73%),
registration staff (50%) and electrocardiogram (ECG)/radiology technicians (50%). Security also had
the highest incidence of physical assault (73%), followed by nursing (49%), PCAs (30%), clinicians
(24%), phlebotomists (17%), and ECG/radiology technicians (13%). A total of 140 (69%) non-security
personnel indicated that they never report incidents of violence.

Conclusion: Our results indicate that violence in the ED affects more than just nurses and doctors.
As health systems seek to improve the safety of their employees in violence-prone areas, it is
imperative that they direct initiatives to the entire healthcare team as no one group is immune. [West
J Emerg Med. 2021;22(3)702-709.]

Section Editor: Gary Johnson, MD
Submission history: Submitted September 26, 2020; Revision received January 30, 2021; Accepted February 17, 2021
Electronically published May 7, 2021
Full text available through open access at http://escholarship.org/uc/uciem_westjem
DOI: 10.5811/westjem.2021.2.50046

Importance
There is a concerning rise in ED violence, with one in five

ED directors reporting guns or knives brought into the ED on
a daily or weekly basis.2 Violence against healthcare workers
continues to make the news, and hospital-based shootings
nearly doubled between 2000–2011.3 Among ED nurses, prior
research has shown an annual incidence of verbal and physical
abuse ranging from 39-98% and 13-67%, respectively.4,5
Among emergency physicians, the incidence has ranged from
75%-96% and 51%-78%, respectively.1,4,5 However, this likely
represents under-reported data as only 30% of nurses and 26% of

Volume 22, no. 3: May 2021 703 Western Journal of Emergency Medicine

McGuire et al. Multidisciplinary Incidence and Reporting of Violence in an ED

Population Health Research Capsule

What do we already know about this issue?
Serious workplace violence incidents are five
times more common in healthcare than other
industries, and events are often not reported.

What was the research question?
What is the incidence of workplace violence
in the emergency department, risk factors, and
why is it under-reported?

What was the major finding of the study?
Most staff, including support disciplines,
experienced violence and most incidents went
unreported.

How does this improve population health?
As health systems seek to improve the safety
of their employees, they must direct initiatives
to the entire healthcare team since no group is
immune.

physicians go on to report incidents of violence.6 According to a
2018 poll from the American College of Emergency Physicians,
nearly 70% of respondents believed that violence in the ED has
increased during the previous five years and nearly 80% felt that
patient care was affected as a result.7

Goals of This Intervention
Exposure to workplace violence impacts the entire team;

however, there is a paucity of research evaluating the incidence of
violence experienced by the ED multidisciplinary care team and
how it compares to institutional reporting. We sought to survey
all staff at our academic ED to identify the incidence of verbal
abuse and physical assault over a six-month period and compare
responses to documented incident reports from the same time
period to evaluate for under-reporting of violence. We also sought
to obtain baseline characteristics of respondents to evaluate for
risk factors for violence or under-reporting. We hypothesized
that nearly all members of the ED multidisciplinary care team
have been exposed to verbal abuse over a six-month time period,
with many of these incidents going under-reported, and that a
significant percentage of staff have also experienced physical
assault during the same time frame.

METHODS
Study Design and Setting

This descriptive prospective study took place between
April–May 2020 within the ED of a large, academic, Level 1
trauma center in a small urban city in the Midwest. The ED sees
an average of 78,000 patients annually and has 24/7 security
presence available.

Selection of Participants

The target population consisted of all ED staff, including
clinicians (attending and resident physicians, and advanced
practice providers [APP]), nursing, care team assistants (CTA)
who provide clerical support and limited patient interaction,
patient care assistants (PCA), electrocardiogram (ECG) and
radiology technicians, phlebotomists, registration staff, and
security officers who worked in the ED at least six months prior
to taking the survey. After review by the institutional review
board (IRB), the survey (described below) was emailed to all
distribution lists for the abovementioned target population
with a cover letter describing the study purpose, directions for
participation, and information regarding informed consent. The
questionnaire included a statement of informed consent at the
beginning, and completion indicated participant consent for
inclusion in the study. Two reminder notices were sent two weeks
apart through the same method. The IRB reviewed this study and
materials and deemed it exempt from approval requirement.

Measurements

We developed an anonymous REDCap survey (Research
Electronic Data Capture, Vanderbilt University, Nashville, TN)8
that included both multiple-choice and Likert-scale response

questions. This survey was distributed broadly by department and
job type to anyone who might work in the ED, even occasionally.
Respondents were asked to self-select for if they had done
any work in an ED in the preceding six months. Participants
were asked to indicate whether they had experienced any of
the following forms of verbal abuse in the prior six months
(October/November 2019–April/May 2020) while working in
the ED: threatening tone of voice; abusive language/statement;
harassment (eg, racial, gender, sexual); or personal verbal threats
(eg, threat of physical or sexual violence, threat of physical
assault to occur outside the workplace). Participants were asked
to indicate whether they had experienced any of the following
forms of physical assault in the prior six months while working
in the ED: physical assault with weapons (including hospital
equipment); physical assault with bodily fluids (eg, saliva, urine,
feces, wound exudate, blood, or spit); or physical assault in the
form of punching, biting, rough handling, scratching, kicking,
shoving/pushing, or hitting. If answering affirmatively to any of
these choices, respondents were asked to indicate whether they
had formally reported the incident.

We used Likert scales to measure participants’ perceptions
of safety and estimated frequency of verbal abuse, physical
assault, and reporting of incidents of workplace violence in
the prior six months. Standard demographic measures were
collected, including gender, profession, primary shift worked,
and years of experience, and whether the employee had worked
in the ED for at least six months. We asked the institution’s

Western Journal of Emergency Medicine 704 Volume 22, no. 3: May 2021

Multidisciplinary Incidence and Reporting of Violence in an ED McGuire et al.

Office of Security to provide de-identified data on the number
of verbal abuse and physical assault incident reports filed by ED
staff during the same time period for comparison.

Outcomes
The primary outcome was the incidence of verbal abuse

and physical assault experienced by ED staff in a six-month
time period as indicated by survey responses. The secondary
outcome was the comparison of this self-revealed data to
formally reported incidents during the same time period.

Data Analysis
Survey responses were summarized with frequency counts

and percentages. We performed group comparisons of survey
responses using chi-squared tests. Pairwise group comparisons
were performed using odds ratios calculated from frequency
counts. Confidence intervals were generated using asymptotic
Gaussian approximation. We converted Likert-scale responses
to the perceptions of safety question to a numeric rank based
on the strength of sentiment. A two-sided Wilcoxon rank-sum
test and Kruskal-Wallis test were performed on these ranks to

compare responses between gender and years-of-experience
groups, respectively. All tests were two-sided and P-values
less than 0.05 were considered significant. We performed
analyses using R version 3.6.2 (The R Foundation for
Statistical Computing, Vienna, Austria).

RESULTS
Characteristics of Study Subjects

A total of 261 responses were received. Seventeen
respondents indicated working in the ED less than six months
and two respondents indicated working in management with
no clinical duties—these 19 responses were excluded from
analysis. We included the 242 remaining responses in our
analysis (Table 1). The cohort was 59.5% female. The most
common positions were nursing staff (80/242, 33.1%), security
(40/242, 16.5%), and attending physicians (28/242, 11.6%).

Violence by Position
Overall, 208 (86%) respondents indicated they had

been verbally abused in the preceding six months (Table 2).
Security officers had the highest incidence of verbal abuse

Female
(N = 144)

Male
(N = 95)

Overall
(N = 242)*

Job position
Clinician 23 (16%) 26 (27.4%) 49 (20.2%)

Attending physician 12 (8.3%) 16 (16.8%) 28 (11.6%)
Resident physician 10 (6.9%) 8 (8.4%) 18 (7.4%)
Advanced practice provider 1 (0.7%) 2 (2.1%) 3 (1.2%)

Care team assistant 11 (7.6%) 0 (0.0%) 11 (4.5%)
Nursing 64 (44.4%) 16 (16.8%) 80 (33.1%)
Patient care assistant 8 (5.6%) 2 (2.1%) 10 (4.1%)
Phlebotomist 16 (11.1%) 8 (8.4%) 24 (9.9%)
Radiology/ECG 14 (9.7%) 10 (10.5%) 24 (9.9%)
Registration 2 (1.4%) 2 (2.1%) 4 (1.7%)
Security 6 (4.2%) 31 (32.6%) 40 (16.5%)

Primary shift
Day 34 (23.6%) 30 (31.6%) 65 (26.9%)
Evening 31 (21.5%) 10 (10.5%) 41 (16.9%)
Night 22 (15.3%) 22 (23.2%) 46 (19.0%)
Rotating 57 (39.6%) 33 (34.7%) 90 (37.2%)

Years of experience
0-4 Years 45 (31.2%) 30 (31.6%) 76 (31.4%)
5-10 Years 33 (22.9%) 21 (22.1%) 55 (22.7%)
11-20 Years 44 (30.6%) 27 (28.4%) 71 (29.3%)
21+ Years 22 (15.3%) 17 (17.9%) 40 (16.5%)

Table 1. Cohort demographics of emergency department staff surveyed about workplace violence.

*3 respondents chose not to disclose gender/sex.
ECG, electrocardiogram.

Volume 22, no. 3: May 2021 705 Western Journal of Emergency Medicine

McGuire et al. Multidisciplinary Incidence and Reporting of Violence in an ED

Position
Any

abuse
Threatening

tone
Abusive

language Harassment
Verbal
threats

Reported
abuse

Clinician 44 (90%) 42 (86%) 38 (78%) 19 (39%) 17 (44%) 1 (2%)
Attending physician 25 (89%) 23 (82%) 23 (82%) 9 (32%) 10 (4%) 1 (4%)
Resident physician 16 (89%) 16 (89%) 12 (67%) 10 (6%) 6 (33%) 0 (0%)
Advanced practice provider 3 (100%) 3 (100%) 3 (100%) 0 (0%) 1 (33%) 0 (0%)
Care team assistant 8 (73%) 7 (64%) 7 (64%) 2 (18%) 1 (9%) 1 (13%)
Nursing 76 (95%) 74 (93%) 72 (90%) 41 (51%) 44 (55%) 8 (11%)
Patient care assistant 9 (90%) 8 (80%) 9 (90%) 3 (30%) 3 (30%) 0 (0%)
Phlebotomist 18 (75%) 12 (50%) 17 (71%) 6 (25%) 2 (8%) 4 (22%)
Radiology/ECG 12 (50%) 10 (42%) 10 (42%) 3 (13%) 1 (4%) 0 (0%)
Registration 2 (50%) 2 (50%) 1 (25%) 0 (0%) 0 (0%) 0 (0%)
Security 39 (98%) 38 (95%) 38 (95%) 27 (68%) 27 (68%) 22 (56%)

Table 2. Incidence of verbal abuse in the prior six months by position.

Note: Reported abuse is given as the percent of respondents who indicated any abuse that reported the incident.
ECG, electrocardiogram.

(98%), followed by nursing (95%), PCAs (90%) and clinicians
(90%), phlebotomists (75%), CTAs (73%), registration staff
(50%), and ECG/radiology technicians (50%). Non-security
and non-nursing personnel indicated an incidence of verbal
abuse of 78%, which was significantly lower than either
security (odds ratio [OR] = 0.08, 95% confidence interval
[CI], 0.01 – 0.62, P <.001) or nursing staff (OR = 0.17, 95%
CI, 0.06 – 0.50, P < .001).

Staff indicated how often they were verbally abused by
patients or family members in the prior six months (Table 3).
Security personnel had the highest proportion of responses
indicating incidents of verbal abuse at least every week (16/40,
40%), followed by nurses (30/80, 38%). For non-security and
non-nurse employees, only 11% of respondents indicated verbal
abuse occurring at least every week, which was significantly
lower than either security (OR = 0.19, 95% CI, 0.08 – 0.45,P <
.001) or nursing staff (OR = 0.22, 95% CI, 0.11 – 0.44, P < .001).

Overall, 90 (37.2%) respondents indicated that they had
been physically assaulted in the preceding six months (Table 4).
Security officers had the highest incidence of physical assault
(73%), followed by nursing (49%), PCAs (30%), clinicians
(24%), phlebotomists (17%), and ECG/radiology technicians
(13%). Neither CTAs nor registration staff revealed any physical
assault. Again, security had the highest frequency of assault, with
29 of 40 (73%) respondents indicating being physically assaulted
at least once. Nurses had the next highest frequency of assault
(39/80, 49%). For non-security and non-nurse staff, 22 (18%)
respondents indicated at least one incident of physical assault.
This frequency was significantly lower than security (OR = 0.08,
95% CI, 0.04 – 0.19, P < .001) and nursing staff (OR = 0.23, 95%
CI, 0.12 – 0.44, P < .001).

Table 5 describes the frequency of reporting events of
workplace violence, grouped by position. Security personnel
had the lowest proportion of respondents indicating they never

report incidents, with seven (18%) responding in this way.
Comparatively, 140 (69%) non-security personnel responded
that they never report incidents. The odds that a non-security
staff member responded “Never” were 11 times higher than for
security personnel (OR = 10.65, 95% CI, 4.47 – 25.38, P < .001).

Violence by Gender
Table 6 provides the number of respondents experiencing

verbal abuse, grouped by gender. Overall, there was no
difference in the incidence of verbal abuse between genders
(female: 85%; male: 87%, P = 0.70). Males were more likely
to report incidents of verbal abuse compared to females (OR
= 3.87, 95% CI, 1.77 – 8.47, P < .001). However, once we
account for employee position, there was no difference in
reporting between males and females. For security personnel,
16/29 (55%) males and 4/6 (67%) females indicated reporting
verbal abuse experienced (OR = 1.63, P = 0.61). For non-
security personnel, 7/53 (13%) males and 7/116 (6%) females
indicated reporting the abuse (OR = 2.37, P = 0.12).

Table 7 summarizes the incidence of physical assault.
There was no significant difference in the overall incidence
of physical assault between genders (female: 33%; male:
43%, P = 0.16). However, males experienced 2.8 times
more occurrences of assault with bodily fluids compared to
females (OR = 2.82, 95% CI, 1.43 – 5.55, P = .002). Males
who experienced physical assault were more likely to report
the incident compared to females (OR = 3.79, 95% CI, 1.57
– 9.18, P = .003). Again, there was no difference in reporting
between males and females after accounting for employee
position. Among security personnel, 19/21 (90%) males
and 5/6 (83%) females indicated reporting physical assault
experienced (OR = 1.9, P = 0.63). For non-security personnel,
only 6/20 (30%) males and 9/41 (22%) females indicated
reporting physical assault experienced (OR = 1.52, P = 0.5).

Western Journal of Emergency Medicine 706 Volume 22, no. 3: May 2021

Multidisciplinary Incidence and Reporting of Violence in an ED McGuire et al.

Position Every day or two Every week Every month Less than every month
Clinician 1 (2%) 5 (10%) 14 (29%) 29 (59%)
Attending physician 1 (4%) 4 (14%) 8 (29%) 15 (54%)
Resident physician 0 (0%) 1 (6%) 4 (22%) 13 (72%)
Advanced practice provider 0 (0%) 0 (0%) 2 (67%) 1 (33%)
Care team assistant 0 (0%) 2 (18%) 3 (27%) 6 (55%)
Nursing 9 (11%) 21 (26%) 34 (42%) 16 (20%)
Patient care assistant 2 (20%) 1 (10%) 1 (10%) 6 (60%)
Phlebotomist 1 (4%) 2 (8%) 2 (8%) 19 (79%)
Radiology/ECG 0 (0%) 0 (0%) 5 (21%) 19 (79%)
Registration 0 (0%) 0 (0%) 0 (0%) 4 (100%)
Security 3 (8%) 13 (32%) 17 (42%) 7 (18%)

Table 3. Frequency of verbal abuse in the prior six months by position.

ECG, electrocardiogram.

Position
Any

assault
Assault-
weapons

Assault-
fluids

Assault-
body

Reported
assault

Reported
abuse

Clinician 12 (24%) 1 (2%) 8 (16%) 8 (16%) 2 (17%) 1 (2%)
Attending physician 7 (25%) 1 (4%) 5 (18%) 3 (11%) 1 (14%) 1 (4%)
Resident physician 4 (22%) 0 (0%) 2 (11%) 4 (22%) 0 (0%) 0 (0%)
Advanced practice provider 1 (33%) 0 (0%) 1 (33%) 1 (33%) 1 (100%) 0 (0%)
Care team assistant 0 (0%) 0 (0%) 0 (0%) 0 (0%) N/A 1 (13%)
Nursing 39 (49%) 5 (6%) 14 (18%) 34 (43%) 12 (31%) 8 (11%)
Patient care assistant 3 (30%) 0 (0%) 1 (10%) 3 (30%) 1 (33%) 0 (0%)
Phlebotomist 4 (17%) 0 (0%) 3 (13%) 3 (13%) 1 (25%) 4 (22%)
Radiology/ECG 3 (13%) 0 (0%) 0 (0%) 3 (13%) 0 (0%) 0 (0%)
Registration 0 (0%) 0 (0%) 0 (0%) 0 (0%) N/A 0 (0%)
Security 29 (73%) 2 (5%) 18 (45%) 28 (70%) 24 (83%) 22 (56%)

Table 4. Incidence of physical assault in the prior six months by position.

Note: Reported abuse is given as the percent of respondents who indicated any abuse and reported the incident.
ECG, electrocardiogram.

Position Always Often Sometimes Rarely Never Not applicable
Clinician 0 (0%) 1 (2%) 2 (4%) 3 (6%) 40 (82%) 3 (6%)
Attending physician 0 (0%) 1 (4%) 2 (7%) 2 (7%) 21 (75%) 2 (7%)
Resident physician 0 (0%) 0 (0%) 0 (0%) 0 (0%) 17 (94%) 1 (6%)
Advanced practice provider 0 (0%) 0 (0%) 0 (0%) 1 (33%) 2 (67%) 0 (0%)
Care team assistant 0 (0%) 0 (0%) 1 (9%) 2 (18%) 7 (64%) 1 (9%)
Nursing 3 (4%) 3 (4%) 5 (6%) 16 (20%) 50 (62%) 3 (4%)
Patient care assistant 1 (10%) 0 (0%) 1 (10%) 2 (20%) 5 (50%) 0 (0%)
Phlebotomist 1 (4%) 0 (0%) 2 (8%) 4 (17%) 15 (62%) 2 (8%)
Radiology/ECG 0 (0%) 0 (0%) 0 (0%) 1 (4%) 19 (79%) 4 (17%)
Registration 0 (0%) 0 (0%) 0 (0%) 0 (0%) 4 (100%) 0 (0%)
Security 14 (35%) 9 (22%) 6 (15%) 1 (2%) 7 (18%) 3 (8%)

Table 5. Frequency of abuse reporting in the prior six months by position.

ECG, electrocardiogram.

Volume 22, no. 3: May 2021 707 Western Journal of Emergency Medicine

McGuire et al. Multidisciplinary Incidence and Reporting of Violence in an ED

Gender Any abuse Threatening tone Abusive language Harassment Verbal threats Reported abuse

Female 122 (85%) 114 (79%) 110 (76%) 59 (41%) 47 (33%) 11 (9%)

Male 83 (87%) 76 (80%) 79 (83%) 40 (42%) 45 (47%) 23 (28%)

Overall 208 (86%) 193 (80%) 192 (79%) 101 (42%) 95 (39%) 36 (17%)

Table 6. Incidents of verbal abuse by respondent gender.

Note: Reported abuse is given as the percent of respondents who indicated any abuse and reported the incident.

Gender Any assault Assault – weapons Assault – fluids Assault – body Reported assault Reported abuse

Female 47 (33%) 5 (3%) 17 (12%) 41 (28%) 14 (30%) 11 (9%)

Male 41 (43%) 2 (2%) 26 (27%) 36 (38%) 25 (61%) 23 (28%)

Overall 90 (37%) 8 (3%) 44 (18%) 79 (33%) 40 (44%) 36 (17%)

Table 7. Incidents of physical assault by respondent gender.

Note: Reported abuse is given as the percent of respondents who indicated any abuse that reported the incident.

Violence by Shift
There was no difference in the overall incidence of verbal

abuse between shifts (x2 = 4.63, P = .20); However, staff
working during the evening reported 69% fewer instances of
abusive tone (OR = 0.31, 95% CI, 0.15 – 0.64, P = .001). Staff
working day or overnight shifts were 4.2 times more likely to
report incidents of verbal abuse compared to those working
evening or rotating shifts (OR = 4.17, 95% CI, 1.85 – 9.39, P
< .001). There was no significant difference in physical assault
related to shifts (x2 = 3.97, P = .26). Moreover, there was no
significant difference in the number of respondents reporting
incidents of assault (x2 = 7.01, P = .071).

Violence by Years of Experience
Staff members with less than four years or more than 21

years of experience were more likely to experience some form
of verbal abuse compared to staff members with 5-20 years of
experience (OR = 2.94, 95% CI, 1.31 – 6.61, P = .007). There
was no difference in the number of respondents reporting their
incidents of verbal abuse between years of experience (x2 = 4.18,
P = .24). There was no difference in the number of respondents
indicating some form of physical assault between experience
groups (x2 = 6.00, P = 0.11). Additionally, there was no difference
in the number of respondents reporting physical assault between
experience groups (x2 = 2.02, P = .57).

Perceptions of Safety
When asked how safe respondents felt as a staff member

working in the ED, 100% of respondents indicated subjectively
feeling safe, with 11.1% indicating feeling extremely safe
(27/242), 48.8% very safe (118/242), 35.5% moderately safe

(86/242), and 4.5% slightly safe (11/242). No respondents
indicated feeling unsafe. Responses were converted to a numeric
rank based on the strength of sentiment, with “slightly safe” the
lowest score at 1 and “extremely safe” the highest score at 4.
Males had a higher perceived safety compared to females (P =
.016). The average response rank for males was 2.81, compared
to 2.56 for females. When evaluating for perceptions of safety
among staff with different years of experience, there was no
significant difference in perceived safety between the experience
groups (P = .40).

Official Incident Reports
During the same six-month time frame respondents were

surveyed, there were only 11 official incident reports made to
the Office of Security regarding verbal threats or harassment
and 18 reports of physical assaults. Compared to self-reported
data from the survey, this corresponds to a 5% and 18%
reporting rate, respectively.

DISCUSSION
Similar to prior research, our survey of ED staff showed a

high incidence of verbal abuse (86%) and physical assault (37%)
within our ED over a six-month time period. Through surveying
the entire multidisciplinary team, we were able to demonstrate
that all team roles experienced verbal abuse at some point in
a six-month time period, and nearly all experienced physical
assault with the exception of CTAs and registration staff. Even so,
interestingly all 242 respondents indicated feeling some degree
of safety in our ED. We recognize that this subjective reporting
of safety may be misleading and may be attributed to a selection
bias as healthcare employees who feel unsafe in their workplace

Western Journal of Emergency Medicine 708 Volume 22, no. 3: May 2021

Multidisciplinary Incidence and Reporting of Violence in an ED McGuire et al.

are more likely to transfer out of the department and may have
been missed by our survey. This finding may also mirror prior
literature that healthcare employees are resistant to the belief that
they are at risk for patient-initiated violence and experience a
complacency in thinking that violence is simply “part of the job.”1

Security personnel were more likely to formally report
incidents compared to non-security personnel victims. This
may be due in part to the nature of their job and the frequency
with which they experience violence, as well as familiarity
with the reporting process as departmental incident reports are
submitted to their office. Concerningly, 69% of non-security
personnel indicated that they never report incidents of violence.
This was corroborated with a review of official incident reports
received during the same time period. Barriers to reporting are
multifactorial and include, as described above, the belief that
violence is “part of the job,” confusion over what constitutes
violence, unfamiliarity with reporting processes, lack of available
time at work for reporting incidents, fear of retribution from
supervisors, and perceived lack of institutional support.1,9
Our study findings indicate that future efforts to increase
incident reporting within the ED should focus on the entire
multidisciplinary team, including visiting staff assigned to non-
ED departments such as phlebotomy, cardiac monitoring (ECG),
and radiology.

In terms of isolating specific risk factors, we found no
difference in the overall incidence of violence between genders;
however, males were significantly more likely to report incidents
of both verbal and physical abuse compared to females. To
our knowledge, this has not been previously described in the
literature. Although we found a difference in the reporting of
violence between genders, this difference was not significant
once we accounted for employee position. This is likely due to a
greater proportion of males in our study working in security (35%
males, 5% females), and security personnel indicating a higher
rate of violence reporting regardless of gender. Future studies
with larger cohort sizes should seek to identify whether there is a
difference in reporting between genders. Coincidentally, females
had a significantly lower perceived perception of safety in our ED
compared to their male counterparts. Thus, additional research
should seek to more clearly establish the reasons why more
females choose not to report incidents of violence.

There was no significant difference in the overall incidence
of violence between shifts; however, staff working daytime or
overnight shifts were more likely to report incidents of verbal
abuse. This may be explained by the higher frequency of incident
reporting by security staff and the fact that security officers in
our institution work 12-hour shifts, considered either day shift
or overnight shifts, with only non-security personnel working
evening or rotating shifts. Future research should continue
to distinguish what additional demographic factors may be
contributing to the lack of violence reporting.

The unique environment of the ED contributes to its
propensity for violence: stress among patients, families, and
visitors; long wait times and delays; crowding; unrestricted

24-hour access; low socioeconomic status; substance abuse;
patients with behavioral health issues; gang activity; and frequent
delivery of “bad news” have all been suggested to contribute to
the elevated incidence of violence.1,10 A multidisciplinary study
of healthcare workers found exposure to workplace violence
significantly correlated with burnout, and a separate survey of
ED nurses found that 94% of those experiencing violence in
the workplace exhibited symptoms of post-traumatic stress.11
In addition to its impact on patient care and detriment to
employee wellbeing, violence has a substantial financial impact
for employers and the economy. Financial costs of workplace
violence include lost time/wages; medical costs of employee
injury, disability, and/or death; and attrition.12 According to a
2017 report commissioned by the American Hospital Association,
hospitals spent an estimated $1.1 billion in security and training
costs to prevent violence, and an additional $429 million to cover
costs such as medical care, staffing, and insurance resulting
from violence against staff.13,14 Future research should attempt to
characterize the mental and physical toll on the multidisciplinary
ED care team to help direct efforts for employee wellbeing.

This study’s findings have important clinical implications.
The incidence of verbal abuse among our multidisciplinary ED
care team was nearly 6 of every 7 staff members, and yet these
incidents were almost never reported to the institution. The
incidence of physical assault was more than 2 of every 5 staff
members and, again, the majority went unreported. Nearly 7 out
of every 10 non-security staff members declined to officially
report the violence they experienced. Findings from this study
suggest that the pervasive nature of violence in healthcare is still
underappreciated and that increased efforts are needed to protect
ED staff members and support and encourage or incentivize
accurate and reliable reporting.

LIMITATIONS
This study has several important limitations. To preserve

anonymity of employees, the study was sent to email distribution
lists (DL) and included some DLs with employees working in
other departments other than the ED (eg, phlebotomy, and ECG
and radiology technicians), or who also worked at additional sites
elsewhere in our health system (eg, clinicians). Thus, it is not
possible to know the actual number of employees from different
disciplines who work in the ED to estimate a response rate for
our survey. Additionally, to further preserve anonymity, we did
not ask in-depth demographic questions. Without knowing full-
time vs part-time status of respondents, it is possible that some
responses came from employees working part time and this may
have skewed our incidence of violence. The definition of “verbal
abuse” is highly subjective to individual respondents and survey
inclusion of “threatening tone of voice’” may have contributed to
over-reporting of verbal abuse in general by respondents.

The study was also subject to recall and reporting bias in
terms of violence experienced over a six-month time period,
as well as the reporting of incidents. We acknowledge that
because this was a single-center study some aspects may not be

Volume 22, no. 3: May 2021 709 Western Journal of Emergency Medicine

McGuire et al. Multidisciplinary Incidence and Reporting of Violence in an ED

generalizable to all institutions or geographic regions. However,
the finding of under-reporting is not dissimilar to other published
studies,15,16 and the fact that abuse and violence affect previously
unstudied populations including ancillary services and clerical
assistant staff is important and not likely related to local factors.

Address for Correspondence: Sarayna S. McGuire, MD, Mayo
Clinic, Department of Emergency Medicine, 200 First St SW,
Rochester, MN 55905. Email: [email protected]

Conflicts of Interest: By the WestJEM article submission agreement,
all authors are required to disclose all affiliations, funding sources
and financial or management relationships that could be perceived
as potential sources of bias. No author has professional or financial
relationships with any companies that are relevant to this study.
There are no conflicts of interest or sources of funding to declare.

Copyright: © 2021 McGuire et al. This is an open access article
distributed in accordance with the terms of the Creative Commons
Attribution (CC BY 4.0) License. See: http://creativecommons.org/
licenses/by/4.0/

REFERENCES
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2. Kansagra SM, Rao SR, Sullivan AF, et al. A survey of workplace

violence across 65 U.S. emergency departments. SAEM. 2008;
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3. Weyand JS, Junck E, Kang CS, et al. Security, violent events,
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Washington state. West J Emerg Med. 2017;18(3)466-73.

4. Gerberich SG, Church TR, McGovern PM, et al. An epidemiological
study of the magnitude and consequences of work related violence:
the Minnesota Nurses’ Study. Occup Environ Med. 2004;61:495-503.

5. Gates DM, Ross CS, McQueen L. Violence against emergency
department workers. J Emerg Med. 2006;31:331-7.

6. Behnam M, Tillotson RD, Davis SM, et al. Violence in the emergency
department: a national survey of emergency medicine residents and
attending physicians. J Emerg Med. 2011;40(5):565-79.

7. Kelly M. Violent attacks against emergency physicians remain a
problem. Ann Emerg Med. 2020(75):11A-4A.

8. Paul A. Harris, Robert Taylor, Robert Thielke, et al. Research
electronic data capture (REDCap) – A metadata-driven methodology
and workflow process for providing translational research informatics
support. J Biomed Inform. 2009; 42(2):377-81.

9. Stene J, Larson E, Levy M, Dohlman M. Workplace violence in
the emergency department: giving staff the tools and support to report.
Perm J. 2015;19(2):e113-7.

10. Lenaghan PA, Cirrincione NM, Henrich S. Preventing emergency
department violence through design. J Emerg Nurs. 2018;44:7-12.

11. Copeland D and Henry M. The relationship between workplace
violence, perceptions of safety, and professional quality of life among
emergency department staff members in a Level 1 trauma centre. Int
Emerg Nurs. 2018;39:26-32.

12. Larson LA, Finley JL, Gross TL, et al. Using a potentially aggressive/
violent patient huddle to improve health care safety. Jt Comm J Qual
Saf. 2019;45:74-80.

13. Taylor JL and Rew L. A systematic review of the literature: workplace
violence in the emergency department. J Clin Nurs. 2010;20:1072-85.

14. Durkin M. Hospital fight back against violence. 2017. Available at:
https://acphospitalist.org/archives/2017/12/hospitals-fight-back-against-
violence.htm. Accessed May 25, 2020.

15. Pompeii LA, Schoenfisch AL, Lipscomb HJ, et al. Physical assault,
physical threat, and verbal abuse perpetrated against hospital
workers by patients or visitors in six U.S. hospitals. Am J Ind Med.
2015;58(11):1194-204.

16. Speroni KG, Fitch T, Dawson E, et al. Incidence and cost of nurse
workplace violence perpetrated by hospital patients or patient visitors.
J Emerg Nurs. 2014;40(3):218-28.

© 2021. Notwithstanding the ProQuest Terms and conditions, you may use this
content in accordance with the associated terms available at

https://creativecommons.org/licenses/by/4.0/

153The Journal of Continuing Education in Nursing · Vol 50, No 4, 2019

Newly Licensed Nurse Resiliency and
Interventions to Promote Resiliency in the First
Year of Hire: An Integrative Review
Lisa Concilio, MSN-ED, RN, CCRN; Joan Such Lockhart, PhD, RN, CNE, ANEF, FAAN;
Marilyn H. Oermann, PhD, RN, ANEF, FAAN; Rebecca Kronk, PhD, MSN, CRNP, CNE, FAAN;
and James B. Schreiber, PhD

The nursing shortage has been a long-standing problem in the United States and spans eight decades (National League for Nurses, 2017).
Newly licensed nurses (NLNs) are graduate RNs who
have passed the National Council Licensure Exam-RN
(NCLEX-RN®) and are employed for the !rst time in
the role as a professional nurse. NLN turnover has been
reported in recent years to a”ect patient safety and com-
pounds the global nursing shortage (Boamah & Las-
chinger, 2015; Bradbury-Jones, 2015; Kovner, Brewer,

Fatehi, & Katigbak, 2014; Spence Laschinger, Zhu, &
Read, 2016; #omas & Kellgren, 2017; World Health
Organization, 2017). #e American population is liv-
ing longer with chronic diseases and expanding disabili-
ties; more well-prepared RNs are needed as health care
is ever-advancing and technology is at the forefront to
help solve health care problems and improve quality of
life (Academy of Medical-Surgical Nurses, 2018; Ghe-
breyesus, 2018; National Academy of Medicine, 2017;
Reinhard, 2014).

PROBLEM IDENTIFICATION AND SIGNIFICANCE
#e American Association of Colleges of Nursing

(2017) reported that 1.2 million RN positions will be
vacant between 2014 and 2022 and that approximately
700,000 nurses will retire or leave the workforce by 2024.
Cline, La Frentz, Fellman, Summers, and Brassil (2017)

abstract
Background: Lack of resiliency contributes to grow-

ing dissatisfaction among newly licensed nurses (NLNs)
and often leads to clinical errors and job resignations.
Method: An integrative review synthesized current re-
search investigating NLNs’ resiliency within their first
year of hire and interventions that may affect their re-
siliency. Results: Key database searches (2008 to 2018)
yielded 16 studies. Insufficient resiliency among NLNs
has been correlated with intentions to leave current
jobs and decreased job satisfaction. Residency pro-
grams, well-prepared preceptors, and peer support
promoted NLN resilience and enhanced patient safety.
Lack of coworker support has led to NLNs’ intentions
to leave their current jobs or the profession entirely.
Conclusion: NLN turnover has been interpreted to be
an outcome of poor NLN resilience. The first year of
practice is stressful and affects NLNs’ mental health
and cognitive reasoning, thereby risking patient safe-
ty. Resiliency should be measured using a resiliency
scale rather than turnover rates. [J Contin Educ Nurs.
2019;50(4):153-161.]

Ms. Concilio is PhD Student, Dr. Lockhart is Professor and MSN Nurs-
ing Education Track Coordinator, Dr. Kronk is Associate Professor, and
Dr. Schreiber is Professor of Epidemiology/Statistics, Duquesne University
School of Nursing, Pittsburgh, Pennsylvania; and Dr. Oermann is !elma
M. Ingles Professor of Nursing, Duke University School of Nursing, Dur-
ham, North Carolina. Ms. Concilio is also Lecturer and Clinical Instructor,
School of Nursing, San Diego State University, San Diego, California.

!e authors thank Dr. Jane Brannan, EdD, Professor of Nursing, Ken-
nesaw State University, Kennesaw, Georgia, for her content expertise and
support. !e authors also thank David Nol”, MLS, AHIP Head, Research
Engagement, Health Sciences/STEM Initiatives, Assessment Coordinator
Gumberg Library, Duquesne University, Pittsburgh, Pennsylvania, for on-
going support.

!e authors have disclosed no potential con#icts of interest, “nancial
or otherwise.

Address correspondence to Lisa Concilio, MSN-ED, RN, CCRN, Lec-
turer and Clinical Instructor, School of Nursing, San Diego State Uni-
versity, 10006 Maya Linda Rd. #5207, San Diego, CA 92126; e-mail:
[email protected]

Received: August 13, 2018; Accepted: October 22, 2018
doi:10.3928/00220124-20190319-05

154 Copyright © SLACK Incorporated

reported that training one NLN may cost a health care
system $60,000 to $96,000; therefore, increasing NLN
resiliency is imperative to maintain patient safety and
is a !nancial priority. NLNs experience immense stress,
leading to a state of shock while transitioning to practice
(Duchscher, 2009) and resulting in burnout and turn-
over (Laschinger et al., 2016; Pfa”, Baxter, Jack, & Ploeg,
2014). Dyrbye et al. (2017) de!ned burnout as a syndrome
characterized by emotional exhaustion that leads to poor
performance and an attitude that is contrary to caring.
Nurse burnout has led to sta$ng shortages and increased
turnover rates, which has resulted in the use of physical re-
straints, patient falls, and the formation of pressure ulcers
(Aiken et al., 2014; Robert Wood Johnson Foundation
[RWJF], 2012).

Resiliency has been identi!ed as a key factor in manag-
ing the stress of nursing work–life, bu”ering burnout, and
positively in%uencing NLNs’ intentions to stay their cur-
rent jobs (Chesak et al., 2015; Cope, Jones, & Hendricks,
2016; Delgado, Upton, Ranse, Furness, & Foster, 2017;
Reyes, Andrusyszyn, Iwasiw, Forchuk, & Babenko-Mould,
2015). Mudd (2016) stated that the concept of resiliency
is elusive and a closer examination of resiliency is needed
in order to decrease burnout and decrease turnover. With-
out resiliency or ways to cope with the emotional stressors
and workplace adversities (Delgado et al., 2017), nurses
(including NLNs) may develop inconsistent thoughts, be-
liefs, and values that will render them unsafe for practice
and increase intentions to leave their jobs (Hart, Brannan,
& De Chesnay, 2014; Stephens, 2012; Tahghighi, Rees,
Brown, Breen, & Hegney, 2017). #is article describes an
integrative review of the literature that examined NLNs’
resiliency within their !rst year of hire and interventions
that a”ect their resiliency.

EXPLORING THE CONCEPT OF
RESILIENCE IN NURSING

#e youngest generation of nurses are the most likely
group of nurses to lack the protective factors of resilien-
cy and leave the profession within the !rst year of hire
(Flinkman, Isopahkala-Bouret, & Salanterä, 2013; RWJF,
2014). Resilience assists a nurse’s psyche to cope with the
negative consequences of workplace stress (Fletcher &
Sarkar, 2013). Stressors encountered by nurses in health
care organizations include an increasing aging population,
growing numbers of patients with chronic illnesses, and
an aging nursing workforce (American Association of Col-
leges of Nursing, 2017). To overcome these organizational
and systemic stressors, nurses have been remediated to
provide excellent customer service and uphold standards
of care; yet, these approaches have not addressed the afore-
mentioned stressors or bolstered nurses’ resilience (Insti-

tute of Medicine, 2014; Spence Laschinger et al., 2016;
Wonder, York, Jackson, & Sluys, 2017).

A resilient nurse receives information and acts on it
to safeguard patients and advocate for their needs (Sieg,
2015). Resiliency is the ability to command psychomotor
skills (the ability to perform tasks and communicate cor-
rectly and in a timely manner) and cognitive-behavioral
skills (cognitive re-framing, mindfulness, compassion,
and emotional intelligence) in order to perform success-
fully while stressed (Academy of Medical-Surgical Nurses,
2018; McAllister & Lowe, 2011). In this article, we pro-
vide current knowledge on the concept of NLN resilience
during the !rst year of hire because the lack of resiliency
causes nurses to act in a manner that is contrary to caring.
As dissatisfaction builds, it leads to an increase in errors
and contributes to NLNs leaving their current jobs (Ga-
briel, Diefendor”, & Erickson, 2011; Hart et al., 2014).
#erefore, a need exists to understand NLN resilience
during the !rst year of hire.

PURPOSE AND SPECIFIC AIMS
#e purpose of this integrative review is to summarize

and synthesize NLN resiliency and interventions used to
promote NLN resiliency within the !rst year of hire in
an e”ort to guide future research in this area. Although
resilience has been widely studied in nurses (Delgado et
al., 2017; Hart et al., 2014; Stephens, Smith, & Cherry,
2017) and nursing students (Stephens, 2012, 2013), few
studies have examined NLN resilience. #is integrative
review explores the past literature to describe factors as-
sociated with a lack of resiliency or its protective factors
and to investigate approaches that increase NLN resil-
iency. #e following speci!c aims guided this integrative
review:
t� What is the state of NLNs’ resiliency within their !rst

year of practice?
t� What are the contributing factors that promote or hin-

der NLNs’ resilience?
t� What are the outcomes associated with NLNs’ resil-

ience or lack of resiliency?
t� What are the current interventions or strategies used to

build protective factors of resilience that lead to NLNs’
intention to stay at their current jobs?

t� What tools have been used to measure NLNs’ resiliency
and have been correlated with intentions to leave jobs?

METHOD
An integrative approach by Whittemore and Kna%

(2005) guided this review of the literature. #is model
included !ve stages (problem identi!cation, literature
search, data evaluation, data analysis, and presentation) to
enhance accuracy and ensure a thorough search.

155The Journal of Continuing Education in Nursing · Vol 50, No 4, 2019

Literature Search
A systematic process was used to review the pri-

mary studies of qualitative and quantitative research
designs (Whittemore & Kna%, 2005). #e process of
conducting an integrative review is to provide an unbi-
ased review of the literature. To retrieve relevant litera-
ture, searches were conducted with the assistance of a
health science librarian using the Cumulative Index to
Nursing and Allied Health Literature (CINAHL®) and
PubMed® databases and restricted to English-language
articles published from January 2008 to May 2018.
#e following subject headings were used to retrieve
articles that included descriptions about NLNs: newly
licensed nurses, resiliency, and intention to leave. #e
Boolean operators AND and OR were used to com-
bine these terms with newly licensed nurse* and nurs*
(Table A; available in the online version of this arti-
cle). Inclusion criteria included (a) the topic addressed
resilience or protective factors leading to resilience in
NLNs; (b) study participants were NLNs within their
!rst year of practice; (c) any research design was used;
(d) the studies were conducted in the United States;
and (e) publication was between January 2008 and May
2018. #e review excluded nonresearch publications,
gray literature, and publications that did not address
the inclusion criteria.

A total of 789 articles were identi!ed from CINAHL
and PubMed using the initial search terms; 56 duplicates
were removed, resulting in 733 publications. As shown
in the PRISMA %ow diagram (Figure 1), 570 articles
were removed based on their abstracts, which did not
meet the inclusion criteria. Next, 163 articles were re-
trieved for full-text evaluation; 147 of these were exclud-
ed as they did not meet the inclusion criteria, leaving 16
articles that comprised the !nal sample for this review
(Anderson, Linden, Allen, & Gibbs, 2009; Bontrager,
Hart, & Mareno, 2016; Clark & Springer, 2012; Cline et
al., 2017; Clipper & Cherry, 2015; Fiedler, Read, Lane,
Hicks, & Jegier, 2014; Fink, Krugman, Casey, & Goode,
2008; Gill, Deagan, & McNett, 2010; Hodges, Keeley, &
Troyan, 2008; Hodges, Troyan, & Keeley, 2010; Kramer
et al., 2013; Li, Early, Mahrer, Klaristenfeld, & Gold,
2014; Martin & Wilson, 2011; McCalla-Graham & De
Gagne, 2015; Olson, 2009; Pellico, Brewer, & Kovner,
2009). #ere was no follow-up with authors to retrieve
additional information.

Sample studies included qualitative (n = 8), quantita-
tive (n = 5), and mixed-methods (n = 3) designs. Quali-
tative studies used case study (n = 2), phenomenological
(n = 3), and grounded theory analyses (n = 3). Quantita-
tive studies were nonexperimental (n = 5) and included
causal-comparative (n = 1) and descriptive analyses (n =

4). Mixed-methods studies used sequential, exploratory
designs (n = 3).

Data Evaluation
#e data evaluation stage used a methodological ap-

proach to appraise the quality of each publication (Whit-
temore & Kna%, 2005). Each quantitative study was
evaluated and categorized based on its quality of evidence
and recommendation level for practice using the GRADE
(Grading of Recommendations, Assessment, Develop-
ment, and Evaluations) Guideline Criteria for Appraising
Quality of Evidence (Schünemann, Ahmed, & Morgan,
2011); for qualitative studies, the GRADE-CERQual
Con!dence in the Evidence from Review of Qualitative
Research (Lewin et al., 2018) was used. Qualitative stud-
ies were evaluated using GRADE-CERQual and catego-
rized using a systematic approach to increase transparency
in the appraisal process. Four components were used to
evaluate qualitative studies: methodological limitations,
coherence, adequacy of data, and relevance. Publication
bias is also important and was considered in the appraisal
of qualitative evidence and placed as a !fth criterion. Elev-

Figure 1. Graphical representation of the flow of citations reviewed.
Adapted from “Preferred reporting items for systematic reviews and
meta-analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J.
Tetzlaff, and D.G. Altman, 2009, Physical Therapy, 89, pp. 873-880.
Copyright 2009 by Moher et al. Adapted with permission.

156 Copyright © SLACK Incorporated

en studies were rated as moderate to low quality (quali-
tative, n = 8; mixed-methods, n = 3) and the remaining
!ve quantitative studies were rated moderate to very low
quality.

A matrix was created to track key data extracted from
each study using the following subheadings: author, pub-
lication year, design, sample population, setting, purpose/
aims, variables, instruments, and the quality appraisal
(Table B; available in the online version of this article).
Evidence was recorded as high, moderate, low, or very low
(Table B). Observational designs were noted using ++,
and experimental studies were noted using ++++ (Lewin
et al., 2018; Ryan & Hill, 2016).

Data Analysis
During data analysis, primary studies were organized,

categorized, summarized, and integrated into a conclu-
sion about the research problem of each study based on
(a) NLNs’ resiliency within the !rst year of practice, (b)
contributing factors of NLNs that promote or hinder re-
silience, (c) the outcomes associated with NLNs’ resilience
or the lack thereof, (d) methods found to build resilience
in NLNs, and (e) an examination of the tools that have
been used to measure NLNs’ resiliency and correlated with
intentions to leave their jobs. Results were synthesized us-
ing a consistent, correlative method to identify patterns
and relationships, create themes, draw conclusions, and
provide a comprehensive summary (Whittemore & Kna%,
2005).

RESULTS
Presentation of data is the !nal stage of an integrative

review, which exhibits detailed evidence from each sample
study (Whittemore & Kna%, 2005). #e presentation also
includes a synthesis of sample studies based on the review’s
purpose and aims.

Description of Sample
All 16 sample studies were published in the United

States and distributed from 2008 to 2017; most studies
(n = 3) were published in 2009, and none were published
in 2013. Studies were published in nine di”erent journals,
and more than one study was included in the Journal of
Nursing Administration (n = 4), !e Journal of Continuing
Education in Nursing (n = 3), and Nursing Outlook (n = 3).

A wide range of sample sizes existed by study designs:
qualitative studies (7 to 612 participants); quantitative
(51 to 558 participants); and mixed-methods (7 to 434
participants). Both male and female NLNs were included
as study participants in half of the studies, with female
NLNs comprising the majority of study participants,
ranging from 83.4% to 94.2%. #e percentage of male

NLNs included as study participants ranged from 5.8% to
16.6%. Conversely, the remaining half of the studies did
not disclose participants’ gender. Reported age ranges of
participants varied among studies, with most NLNs rang-
ing from 21 to 25 years; two studies repeated mean ages of
33 and 33.4 years; and one study reported a median age of
38.6 years. Other studies reported diverse age ranges: 18
years or over (n = 1); 21 to 50 years (n = 1); 20 to 25 years
(n = 1); and younger than 30 years (n = 1).

Only four studies reported the participants’ race/eth-
nicity. Caucasian was the highest group represented (n =
4, 54.7%) followed by Black (n = 4, 13.6%), Latino (n =
3, 6.1%), and Asian (n = 2, 16.7%). Study settings were
mainly inpatient care settings in medical centers and hos-
pitals across the United States.

NLN Resiliency
Literature published over the past decade revealed that

NLNs’ resiliency must be fostered for NLNs to remain
at their current jobs. Insu$cient resiliency among NLNs
has been correlated with intentions to leave current jobs,
turnover, and decreased job satisfaction. According to the
sample studies (n = 14), most NLNs want to leave their
jobs due to dissatisfaction with nursing work and/or their
work environments (Anderson et al., 2009; Bontrager
et al., 2016; Clark & Springer, 2012; Cline et al., 2017;
Clipper & Cherry, 2015; Fiedler et al., 2014; Fink et al.,
2008; Gill et al., 2010; Hodges et al., 2008; Hodges et al.,
2010; Kramer et al., 2013; Li et al., 2014; Martin & Wil-
son, 2011; McCalla-Graham & De Gagne, 2015; Olson,
2009; Pellico et al., 2009).

Factors That Promote or Hinder NLN Resiliency
Residency programs and coworker support were re-

ported to enhance NLNs’ intentions to remain in their
current jobs and the nursing profession. Residency pro-
grams speci!cally designed to address the needs of NLNs
positively a”ected NLN resiliency (Anderson et al., 2009;
Cline et al., 2017; Fiedler et al., 2014). #e protective fac-
tors of resilience that emerged among the sample studies
were social support (Clipper & Cherry, 2015; Fiedler et
al., 2014; Hodges et al., 2008; Li et al., 2014; Martin &
Wilson, 2011), group cohesion (Anderson et al., 2009;
Bontrager et al., 2016; Gill et al., 2010; Li et al., 2014),
well-prepared preceptors (Bontrager et al., 2016; Clip-
per & Cherry, 2015), relationship-based care practices
(Clark & Springer, 2012; Clipper & Cherry, 2015; Fink
et al., 2008; Kramer et al., 2013; McCalla-Graham & De
Gagne, 2015; Olson, 2009; Pellico et al., 2009), organi-
zational support (Fiedler et al., 2014; Fink et al., 2008;
Olson, 2009), and plentiful clinical support (Fink et al.,
2008).

157The Journal of Continuing Education in Nursing · Vol 50, No 4, 2019

NLN resiliency decreased when NLNs experienced
verbal abuse from physicians and incivility among other
sta” nurses (Kramer et al., 2013; Martin & Wilson, 2011;
Olson, 2009; Pellico et al., 2009). #eir inability to meet
expectations of preceptors, unengaged preceptors, and de-
creased support when making errors also hindered NLNs’
con!dence and job satisfaction which, in turn, negatively
a”ected their resiliency (Gill et al., 2010; Li et al., 2014).

Outcomes Associated With NLN Resiliency
Positive Outcomes. NLN resiliency, which has been in-

ferred as NLNs who want to stay in their jobs (McAllister
& Lowe, 2011), improves empathy toward patients, job
engagement, augmented teamwork, enhanced ability to
perform tasks, boosted con!dence, adaptability, and im-
proved clinical reasoning. All these outcomes of resiliency
assist in closing the preparation–practice gap and enhance
patient safety (Fink et al., 2008; Martin & Wilson, 2011;
Olson, 2009).

Negative Outcomes. #e most common outcome as-
sociated with poor NLN resiliency cited in the nurs-
ing literature is high turnover (Anderson et al., 2009;
Bontrager et al., 2016; Clark & Springer, 2012; Cline et
al., 2017; Clipper & Cherry, 2015; Fiedler et al., 2014;
Fink et al., 2008; Gill et al., 2010; Hodges et al., 2008;
Hodges et al., 2010; Kramer et al., 2013; Li et al., 2014;
Martin & Wilson, 2011; McCalla-Graham & De Gagne,
2015; Olson, 2009; Pellico et al., 2009). Second, a lack
of support from preceptors, sta”, physicians, and other
NLNs increases NLNs’ intentions to leave their jobs or
the profession entirely (Anderson et al., 2009; Li et al.,
2014; Martin & Wilson, 2011; Olson, 2009). Finally,
poor resiliency decreases an NLN’s capability to work in
a team setting (Bontrager et al., 2016; Clark & Springer,
2012; Fink et al., 2008; Gill et al., 2010; Hodges et al.,
2008; Hodges et al., 2010; Kramer et al., 2013; Mar-
tin & Wilson, 2011; Pellico et al., 2009). Teamwork is
the cornerstone of patient care delivery as clinicians col-
laborate and use enhanced communication to bene!t
patients to attain mutual goals (World Health Organiza-
tion, n.d.). As NLN resiliency decreases, so does patient
safety.

Methods to Build Resiliency
and Decrease Turnover

Nurse residency programs have been reported to build
NLN resiliency and decrease turnover or the intention to
leave a job (Anderson et al., 2009; Bontrager et al., 2016;
Clark & Springer, 2012; Cline et al., 2017; Fiedler et al.,
2014; Fink et al., 2008; Gill et al., 2010; Kramer et al.,
2013; Li et al., 2014). Residency programs coordinate
group learning and utilize a buddy system approach to

on-the-job learning; residency programs were reported
to increase socialization, which Dyer and McGuinness
(1996) reported is a protective factor of resiliency. Eleven
of the sample studies concluded that collegial relation-
ships, social support, and professional acculturation were
formidable and essential to cope with stress of a chaotic,
foreign, and challenging work environment (Anderson
et al., 2009; Bontrager et al., 2016; Fiedler et al., 2014;
Fink et al., 2008; Gill et al., 2010; Hodges et al., 2008;
Hodges et al., 2010; Li et al., 2014; Martin & Wilson,
2011; McCalla-Graham & De Gagne, 2015; Olson,
2009). Hodges et al. (2010) and Fiedler et al. (2014) de-
scribed NLNs building comradery with others to negate
feelings of inadequacy as method to protect themselves
from the daily assault of stress and self-doubt. Addition-
ally, Martin and Wilson (2011) described NLNs forming
caring groups to enhance collegial relationships; these
supportive groups helped to decrease feelings of doubt
and stress experienced during their transition from aca-
demia to practice.

Measuring Resiliency and the Outcomes
#is integrative review presents studies that correlated

resiliency using satisfaction surveys, evaluations of precep-
tor e”ectiveness, and intention to leave surveys to best un-
derstand the reasons why NLNs leave their jobs. Table C
(available in the online version of this article) outlines the
tools used in sample studies (n = 8) to evaluate strategies
to build NLN resiliency (Anderson et al., 2009; Bontrager
et al., 2016; Clark & Springer, 2012; Cline et al., 2017;
Clipper & Cherry, 2015; Fiedler et al., 2014; Fink et al.,
2008; McCalla-Graham & De Gagne, 2015). Studies
did not evaluate patient outcomes while measuring NLN
satisfaction or intention to leave. Yet, Gill et al. (2010)
explored NLNs’ work perspectives to gauge nursing qual-
ity by using the 10-item abbreviated version of the Na-
tional Database of Nursing Quality Indicators (NDNQI)
(reliability coe$cient = .91; Taunton et al., 2004). #e
NDNQI was correlated with intentions to leave one’s job,
yet the majority of the participants (n = 7) in this study
intended to leave their current job despite indicating they
were satis!ed. #e same !nding was reported by Clark
and Springer (2012), in which NLNs expressed intentions
to leave their jobs despite being satis!ed with the care they
delivered (n = 37).

DISCUSSION
An iterative process of examining each sample study to

identify patterns, themes, noting intervening factors, and
relationships between variability (Whittemore & Kna%,
2005) was done to clarify, summarize, and synthesize what
is known about the phenomenon of resiliency in NLNs,

158 Copyright © SLACK Incorporated

within the !rst year of hire, in an e”ort to guide future
research in this area.

First, the concept of NLN resiliency is not well un-
derstood as NLN turnover has been interpreted to be
an outcome of poor NLN resiliency. Second, the expec-
tation of NLNs is to take on new responsibilities and
overcome numerous challenges to integrate themselves
into a practice environment that stresses teamwork;
this belief is so overwhelming that it negatively a”ects
NLNs’ mental health. #ird, these feelings drain NLNs,
which, in turn, can cause cognitive and emotional la-
bility and a”ect clinical reasoning, a clear and present
danger to patient welfare. Finally, resiliency should be
measured using a resiliency scale, as the decision or in-
tention to leave one’s job is not a surrogate to determine
NLN resilience.

A growing body of research indicates NLNs’ attri-
tion is increasing at an alarming rate, despite residency
programs assisting in their transition to help them as-
sume professional responsibilities for which they may
be unprepared (Clark & Springer, 2012; Cline et al.,
2017; RWJF, 2014). Nurse incivility among sta”, in-
cluding NLNs, occurs due to the high-stakes climate
and coworkers’ ine”ective communication skills (Las-
chinger, Wong, Regan, Young-Ritchie, & Bushell,
2013). A paradox ensues as NLNs believe they would
be cared for by caring professionals in a caring environ-
ment (Hart et al., 2014; Hodges et al., 2008; Marine,
Ruotsalainen, Serra, & Verbeek, 2006; Martin & Wil-
son, 2011; Pariyo, Kiwanuka, Rutebemberwa, Okui, &
Ssengooba, 2008).

Implications for Practice, Policy, and Research
#e implications for this integrative review provide

information to hospital educators and administrators re-
garding the trends and needs of NLNs and adds a new
perspective on workforce readiness in an e”ort to pro-
mote patient safety. Nursing research has used a positiv-
ist approach to assess NLN resiliency, a philosophy that
has not advanced nursing science in this area. Millennials
(ages 22 to 37) (Dimock, 2019) comprise the majority of
newcomers to the nursing workforce and have the high-
est attrition rate among any generation that has entered
the nursing profession (RWJF, 2014). #erefore, nurse
researchers must apply a social constructivist approach,
as there is much to learn about the Millennial generation
in the workplace (Veesart, 2018). A social constructivism
approach encourages a participant’s own interpretation of
the situation to better understand the meaning of their
experience (Dahnke & Dreher, 2010). #is sociological
lens may help researchers, managers, and educators evalu-
ate NLN resilience as a truth created by their own per-

ceptions rather than through job satisfaction surveys or
intention to leave scales. #e American Academy of Nurs-
ing Policy agrees there is a need to build NLNs’ resilience
(Goode, Glassman, Ponte, Krugman, & Peterman, 2018)
to mitigate the negative e”ects of stress and encourage in-
tention to stay at their !rst job is paramount. Research
regarding low-cost, social support strategies to encourage
NLNs’ motivation and engagement in nursing is needed
to garner patient safety.

Limitations
Several limitations existed among the sample studies

that may result in the !ndings not being applicable to
each NLN’s experience during their !rst year of hire or
to their abilities to build resiliency. For example, detailed
information was not provided regarding sample char-
acteristics such as age in nine studies (Anderson et al.,
2009; Clark & Springer, 2012; Fink et al., 2008; Hodges
et al., 2008; Kramer et al., 2013; Li et al., 2014; Martin
& Wilson, 2011; McCalla-Graham & De Gagne, 2015;
Olson, 2009). Additionally, there was minimal represen-
tation of men in all sample studies, as well as a poor
representation of ethnic/racial diversity. Various prac-
tice settings among the studies limited generalizability
of the !ndings as the settings included medical centers,
hospitals, and specialty units (i.e., oncology). Each set-
ting used di”erent ways to orient NLNs and participants
faced varying types of experiences, which may not repre-
sent all NLNs’ experiences when transitioning into their
!rst jobs.

#e designs of the 16 sample studies were primar-
ily surveys or qualitative interviews. One study did not
report the reliability and validity of the instrument used
(Anderson et al., 2009). Researchers did not directly mea-
sure participants’ resilience in any of the sample studies
yet inferred that participants’ resilience was low if they
intended to leave their jobs. #is ambiguity may have
led to a lack of di”erentiation among the search terms, as
turnover and intention to leave have been correlated with
resilience. However, strategies that encourage group cohe-
siveness, managerial involvement, and adequately prepare
preceptors for what Duchscher (2007, p. 23) referred to as
the “transition shock” period may increase resiliency and
decrease intentions to leave (Anderson et al., 2009; Bon-
trager et al., 2016; Clark & Springer, 2012; Cline et al.,
2017; Clipper & Cherry, 2015; Fiedler et al., 2014; Fink
et al., 2008; Gill et al., 2010; Hodges et al., 2008; Hodges
et al., 2010; Kramer et al., 2013; Li et al., 2014; Martin
& Wilson, 2011; McCalla-Graham & De Gagne, 2015;
Olson, 2009; Pellico et al., 2009; RWJF, 2014). Despite
these e”orts, NLN attrition rates continue to rise each
year.

159The Journal of Continuing Education in Nursing · Vol 50, No 4, 2019

CONCLUSION
#is integrative review provides pertinent informa-

tion to researchers, managers, educators, and health care
administrators about the concept of NLN resiliency. De-
creased resiliency threatens patient safety. NLNs expressed
di$culties feeling con!dent, which, in turn, a”ects profes-
sional development—a factor that is crucial to preparing
a competent workforce. A supportive sta” of nurses and
physicians who are empathetic to the challenges NLNs
face during the !rst year of hire is a proven facilitator of
NLN resiliency; these supportive attributes increase NLN
job engagement, con!dence, and enhances team building
skills. Additionally, resilience may be an indicator of prac-
tice readiness, a vital key to motivate and retain NLNs.

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Table A

Search Terms by Databases Used in the Literature Search

Database Search Term Headings Used: Newly Licensed Nurse, Leaving within
First Year, and Resiliency

No. of
Titles and
Abstracts

CINAHL
search
terms

( (“Newly licensed nurse*” OR (MH “New Graduate Nurses”) OR ((MH
“Nurses+”) OR nurse*) AND (MH (“Internship and Residency) OR MH
(“Transitional Programs) OR MH (“Employee Orientation) OR MH
(“Preceptorship))) )
AND
( (MH “Personnel Retention”) OR (MH “Personnel Turnover”) OR
Retention OR Turnover OR Attrition OR Quit OR Stay OR “Negative
Nurse Outcomes” OR “Intention to Leave” OR “Intention to Quit” OR
(MH “Intention”) OR (MH “Personnel Attitudes”) OR (MH
“Motivational factors for turnover intention”) OR (MH “Professional
Identity”) OR (MH “Locus of control”) OR (MH “Negative Patient
Outcomes”) OR (MH “Willingness to leave”) OR Manpower OR
“Motivational factors” OR “Psychosocial Factors” OR “negative patient
outcomes”)
AND
( (MH (“Adaptation, Occupational”) OR (MH “Avoidance
(Psychology)” OR (MH “Coping”) OR (MH “Cultural Safety”) OR (MH
“Disengagement”) OR (MH “Disruptive Behavior”) OR (MH
“Hardiness”) OR (MH “Job Satisfaction”) OR (MH “Optimism”) OR
(MH “Reality Shock”) OR (MH “Self-Efficacy”) OR (MH “Social
Adjustment”) OR (MH “Stress Disorders, Post-Traumatic+”) OR (MH
“Stress, Occupational”) OR (MH “Support, Psychosocial”) OR (MH
“Symptom Distress”) OR (MH “Symptom Distress”) OR (MH
“Vulnerability”) OR “Nurse Shock” OR “Occupational Adaptation” OR
“occupational shock” OR “personal identity disturbance” OR “Post-
Traumatic Stress Disorder” OR “Professional ident*” OR “psychological
capital” OR “Reality Shock” OR Coping OR Optimis* OR Protective
factors OR PTSD OR Resiliency) OR (MH “Motivation”) OR (MH
“Psychological Factors”) OR (MH “Occupational Coping”) OR (MH
“Shared decision-making”) OR (MH “Workplace empowerment”) OR
(MH “growth mindset”) OR (MH “Prevention and Control”) OR (MH
“Occupational Commitment”) OR (MH “Professional commitment”) OR
(MH “Controlled Motivation”))

397

PubMed
search
terms

(((( “Emotional Adjustment”[Mesh]) AND “Sense of Coherence”[Mesh]
OR “Resilience, Psychological”[Mesh] OR “Adaptation,
Psychological”[Mesh] OR “Problem Behavior”[Mesh] OR “disruptive
behavior”[tiab] OR “disruptive behavior”[ot] OR “Job
Satisfaction”[Mesh] OR “Absenteeism”[Mesh] OR

392

Note. CINAHL = Cumulative Index to Nursing and Allied Health Literature.

“Presenteeism”[Mesh] OR “Optimism”[Mesh] OR “Self
Efficacy”[Mesh] OR “Social Adjustment”[Mesh] OR “Stress Disorders,
Post-Traumatic”[Mesh] OR “Social Support”[Mesh] OR “Nurse Shock”
[tiab] OR “Occupational Adaptation” [tiab] OR “occupational shock”
[tiab] OR “personal identity disturbance” [tiab] OR “Post-Traumatic
Stress Disorder” [tiab] OR “Professional identity” [tiab] OR
“Professional identities”[tiab] OR “psychological capital” [tiab] OR
“Reality Shock” [tiab] OR Coping[tiab] OR Optimis*[tiab] OR
“Protective factor” [tiab] OR “Protective factors” [tiab] OR PTSD[tiab]
OR Resiliency[tiab] OR “Nurse Shock” [ot] OR “Occupational
Adaptation” [ot] OR “occupational shock” [ot] OR “personal identity
disturbance” [ot] OR “Post-Traumatic Stress Disorder” [ot] OR
“Professional identity” [ot] OR “Professional identities”[ot] OR
“psychological capital” [ot] OR “Reality Shock” [ot] OR Coping[ot] OR
Optimis*[ot] OR “Protective factor” [ot] OR “Protective factors” [ot]
OR PTSD[ot] OR Resiliency[ot] OR “Motivation”[Mesh] OR
“psychology” [Subheading] OR “Decision Making”[Mesh] OR
“Prevention and Control”[Subheading]))) AND ((Quit[ot] OR Quit[tiab]
OR retention[ot] OR Retention[tiab] OR Stay[ot] OR Stay[tiab] OR
Turnover[ot] OR Turnover[tiab] OR “Personnel Turnover”[Mesh] OR
“Personnel Loyalty”[Mesh] OR Retention[tiab] OR Retention[ot] OR
Turnover[tiab] OR Turnover[ot] OR Attrition[tiab] OR Attrition[ot] OR
Quit[tiab] OR Quit[ot] OR Stay[tiab] OR Stay[ot] OR “Negative Nurse
Outcomes”[tiab] OR “Negative Nurse Outcomes”[ot] OR “Intention to
Leave”[tiab] OR “Intention to Leave”[ot] OR “Intention to Quit”[tiab]
OR “Intention to Quit”[ot] OR Manpower[tiab] OR “Motivational
factors” [tiab] OR “Psychosocial Factors” [tiab] OR “negative patient
outcomes” [tiab] OR Manpower[ot] OR “Motivational factors” [ot] OR
“Psychosocial Factors” [ot] OR “negative patient outcomes” [ot]))) AND
((“Newly licensed nurse”[tiab] OR “Newly licensed nurse”[ot] OR
“Newly licensed nurses”[tiab] OR “Newly licensed nurses”[ot] OR
“New Graduate Nurse”[ot] OR “New Graduate Nurse”[ot] OR “New
Graduate Nurses”[ot] OR “New Graduate Nurses”[ot] OR “Novice
nurse” [tiab] OR “Novice Nurse”[ot] OR “Novice nurses” [tiab] OR
“Novice Nurses”[ot] OR “Newly licensed nurse*”[tiab] OR “New
Graduate Nurses”[ot] OR “Novice nurse” [tiab] OR “Novice Nurses”[ot]
OR (“Nurses”[Mesh] OR nurse*[tiab] OR nurse*[ot]) AND (“Internship,
Nonmedical”[Mesh] OR “Inservice Training”[Mesh] OR
“Preceptorship”[Mesh]))

Total no.
of
citations
including
duplicates

789

T
able B

Sum

m
ary of F

indings from
R

esearch Studies (N
=

16)
__________________________________________________________________________________________________________
A

uthor/year
D

esign/M
ethod

Sam
ple population/ Purpose, A

im
s, Findings A

ppraisal R
ating/

Setting V
ariables, and Q

uality of E
vidence

Instrum
ents using G

R
A

D
E

or
G

R
A

D
E

-C
E

R
Q

ual

_____________________________________________________________________________________
A

nderson et
al. (2009)

m
ixed m

ethods/
sequential
exploratory

90 new
graduate

nurses, gender and
ethnicity not
reported/interactive
nurse residency

Purpose: to com
pare

perceived job
satisfaction and
em

ployee
engagem

ent of new

graduate nurses
com

pleting an
interactive nurse
residency.
A

im
s: to m

easure job
satisfaction and
engagem

ents
perceptions of new

nurses after
com

pleting
interactive residency
m

odules and to test
the environm

ent
nursing satisfaction
survey.
V

ariables: change for
nurse residency –

Q
ualitative results

revealed 2 them
es

(protective factors
of resiliency
em

erged): w
hat

satisfied nurses
(patients, patient
outcom

es, and
team

w
ork) and w

hat
did not satisfy
nurses
(staffing/scheduling,
lack of team

w
ork,

M
D

disrespect).
Q

uantitative results:
“A

fter the nurse
residency sessions
and 1 year later, the
quantitative findings
on the H

alfer-G
raf

survey revealed that
the nurse residents

+
+




R

isk of bias: T
here

w
ere lim

itations in
detailed design as the
outcom

e w
as not

confidently
determ

ined as the
tool’s psychom

etrics
w

ere not discussed.
T

here w
as no

discussion about the
H

alfer-G
raf Job/W

ork
E

nvironm
ent N

ursing
Satisfaction Survey
other than stating it
w

as reliable and valid
as previously stated in
previous studies.
M

ost inform
ation w

as
stated from

studies at

im
plem

entation of a
2- day interactive
nurse residency.
Instrum

ents: H
alfer-

G
raf Job/W

ork
E

nvironm
ent N

ursing
Satisfaction Survey
(psychom

etrics not
reported)

significantly
perceived that they
w

ere able to
perform

their job,
identify resources,
understand
perform

ance
expectations,
accom

plish w
ork

tasks, and m
anage

the dem
ands of the

job effectively” (p.
168).
A

n interactive
learning
environm

ent assists
new

graduate nurses
in job satisfaction
and em

ployee
engagem

ent. M
ost

valuable strategy
w

as em
ail

com
m

unication as a
form

of support (a
protective factor of
resiliency).

low
or unclear risk of

bias. T
his denotes

serious risk of bias,
dow

n grade one level
(R

yan, 2016).
Inconsistency: the
sam

ple w
as from

one
cohort of new

graduate nurses and
one period in tim

e.
T

his denotes som
e

inconsistency and a
dow

ngrade of one
point is recom

m
ended

(R
yan, 2016).

Indirectness: the
author answ

ered the
question of w

hether
this particular cohort
w

ere satisfied and
engaged by using
interactive residency
m

odules.
Im

precision:
C

onfounding
variables w

ere not
discussed as to other
reasons to the 4%

increase of new

graduate nurse
retention w

hen
com

pared to past
years. T

here w
as not

enough inform
ation to

detect a precise
estim

ate of the effect
(interactive residency
m

odules on new

graduate satisfaction
and job engagem

ent).
Publication bias: N

ot
detected, Journal of
N

ursing
A

dm
inistration has

various studies of size
and design.

B
ontrager et

al. (2016)
quantitative/
descriptive,
prospective, cross-
sectional

84 new
ly licensed

registered nurses
enrolled in a residency
program

. 5.8%
of

participants w
ere m

ale.
66.7%

participants
w

ere C
aucasian, 17.9%

w

ere black, 3.6%

L
atino, and 7.1%

A

sian.

Purpose: to
understand how

preceptor role
effectiveness and
group cohesion affect
N

L
N

s’ satisfaction
and intent to stay.
A

im
s: W

hat w
ere the

relationships am
ong

preceptor role
effectiveness, group
cohesion, and job
satisfaction am

ong
N

L
N

s? W
hat w

ere
the relationships
am

ong preceptor role
effectiveness, group
cohesion, job
satisfaction, and

H
igh levels of

intention to stay at
job w

as perceived
by nurses due to the
role of preceptors,
job satisfaction, and
group cohesion
(protective factor of
resiliency).
Preceptors that are
effective ensure a
quality orientation
and can help
socialize a new

nurse and encourage
job satisfaction.
G

roup cohesion w
as

found to be vital to
increase feelings of

+
+




R

isk of bias: T
ool

psychom
etrics w

ere
reported and
C

ronbach D
scores

show
ed reliability and

validity. T
he

tools/scales w
ere

justly chosen to
predict the outcom

e
level.
Inconsistency: the
sam

ple w
as not

discussed regarding
units w

orked on or
shift w

orked. T
he

ability to exam
ine

intent to stay am
ong

N
L

N
s?

V
ariables: D

V
:

preceptor role
effectiveness, group
cohesion, and job
satisfaction
Instrum

ents:
Preceptor R

ole
E

ffectiveness Scale,
N

urse Job
Satisfaction Scale,
Intent to Stay
Scale.

value, reduce
burnout, stress and
anxiety. G

roup
cohesion is
im

portant to reduce
transition shock and
intention to stay.

changes during the
orientation period w

as
not discussed.
D

oubtful that there
are large variations in
the degree to w

hich
the outcom

e is
affected, no
dow

ngrade if on the
basis that it does not
seem

to be an issue.
Indirectness: T

here
w

as evidence of
indirectness as the
outcom

e w
as assessed

at only one period in
tim

e w
hich lim

ited
the ability to exam

ine
changes. T

he
evidence that w

as
found w

as m
ore

restrictive than the
review

question and
m

ay not directly
answ

er the review

question, “W
hat w

ere
the relationships
am

ong preceptor role
effectiveness, group
cohesion, and job
satisfaction am

ong
N

L
N

s? W
hat w

ere the

relationships am
ong

preceptor role
effectiveness, group
cohesion, job
satisfaction, and
intent to stay am

ong
N

L
N

s?” D
ow

ngraded
one point as som

e
indirectness exists.
Im

precision: good
correlation w

ith
prim

ary studies, no
im

precision detected.
Publication bias: N

ot
detected, T

he Journal
of C

ontinuing
E

ducation in N
ursing

has various studies of
size and design.

C
lark &

Springer
(2012)

qualitative/
case study m

odel

37 new
graduate nurses

in a nurse residency
program

across m
any

specialty areas/
northw

estern U
S

15.6%
of participants

w
ere m

ale. T
he

ethnicity of participants
w

as not reported.

Purpose: to exam
ine

the lived experience
as new

nurses to
assess the level of job
satisfaction during
the first year of
practice.
A

im
s: 1. H

ow
do new

graduate nurses
describe their typical
w

orkday?
2. W

hat are the m
ost

satisfying aspects of

T
hem

es that
em

erged: learning
to w

ork in chaos,
feeling valued,
stress of the
unknow

n, life-long
learning, and
preserving the
profession.
Preceptors and staff
are vital to
enhancing job
satisfaction and

+
+




M

ethodical
lim

itations: Prim
ary

studies revealed
conflicting evidence
regarding the lived
experiences of new

nurses. W

e are
confident that the
findings in this study
reflect this sm

all

the new
graduate

nurses’ nursing?
3. W

hat are the m
ost

concerning aspects of
the new

graduate
nurses’ practice?
4. W

hat educational
topics do new

graduate nurses
w

ant to know
m

ore
about?
5. W

here do the new

graduate nurses see
them

selves
practicing nursing in
the future?
V

ariables: D
V

: job
satisfaction
Instrum

ents: open-
ended questions

com
m

itm
ent to

nursing. Support
(protective factor of
resiliency) w

as
m

entioned to
im

prove job
satisfaction. T

he
stress of life-long
learning w

as
divided into sub-
them

es that
included dealing
w

ith incivility,
adapting to change,
and stress
m

anagem
ent.

Participants
described being
valued by
colleagues as a
m

ajor contributor to
job satisfaction.
O

rganizations can
help new

nurses feel
valued by using
relationship-based
care and increasing
collegial
relationships as
w

ays for enhancing
satisfaction and
feelings of
com

petence. Som
e

sam
ple’s lived

experience as it did
represent w

hat w
as

found in prim
ary

studies discussed.
R

elevance: N
ew

nurses are
experiencing a new

environm

ent and w
ay

to function yet one of
the research questions
asked about
educational topics
they m

ay w
ant to

know
m

ore about.
T

he prem
ise of being

“new
” and the chaos

this brings, it seem
s

contrary and not
relevant to pursue this
aim

. N
ot applicable to

the context specified
in describing the lived
experience of a new

nurse; dow

ngraded
one point.
C

oherence: T
here is

good fit betw
een the

data from
the prim

ary
studies and the review

findings.
A

dequacy of data:
T

here is good

participants stated
preceptors w

ere
unsupportive and
disinterested and
this decreased job
satisfaction. T

his
also increased stress
and decreased new

nurses’ ability to
w

ork in team
s.

am
ounts of data

supporting the review

finding and this aligns
w

ith prim
ary studies

about the lived
experiences of new

nurses.
Publication bias:
N

ursing O
utlook has

published diverse
studies designs w

ith
various sam

ple sizes.

C
line et al.

(2017)
Q

uantitative/
descriptive,
retrospective
analysis of 10
years of residency
data

First stated over 1,000
participants’ data w

ere
analyzed then table
show

ed 558 new
nurses

w
ithin 12 m

onths of
hire/residency program

in a cancer center
w

ithin the U
S 8.9%

w

ere m
ale participants.

Percentage of
C

aucasian participants
w

as 36%
, B

lack
21.6%

, L
atino 12.2%

,
A

sian 26.3%
.

Purpose: to present a
10-year retrospective
review

of outcom
es

from
an internally

developed nurse
residency program

A

im
s: an analysis of

an internally
developed residency
program

on the
developm

ent of new

nurses.
V

ariables:
“custom

ized” nurse
residency program

at
one cancer care
center and w

as
“enhanced” over
tim

e, sim
ulation w

as

Scores in support
declined over the
course of the
residency program

w

hich decreased
professional
satisfaction. T

he
C

asey-Fink scores
revealed
participants’ stress
levels w

ere low

during this
residency program

,
this is not consistent
w

ith prim
ary studies

or new
ly licensed

nurses’ experiences
in the literature. T

he
authors suggested
that findings

+
+




R

isk of bias: there
w

ere lack of details in
the design and
execution as the
residency program

over tim

e had m
any

changes.
Inconsistency: there
w

as little
understanding of the
outcom

es from
this

longitudinal study and
how

the data
supported the
outcom

e that
residency program

s
assist in new

nurse

also added through
the years.
Instrum

ents: C
asey-

Fink G
raduate N

urse
E

xperience Survey,
institutional retention
m

etrics

developed in this
“custom

” residency
program

em

phasized that a
program

just about
entry to practice can
com

fort new
nurses

and prom
ote

confidence
(protective factor of
resiliency) w

hich
w

ill lead to positive
retention.

job satisfaction and
therefore retention.
Indirectness:
applicability of this
custom

ized residency
program

(undetailed)
did not help reader to
understand the
phenom

enon of new

nurse retention or the
ability to enhance
dealing w

ith stress or
adversity (resilience).
Im

precision: there is a
large am

ount of
inadequacy due to the
levels of stress
reported and the
confounding variables
such as the
possibilities of
financial stress due to
the level of support
the hospital m

ay have
offered participants as
opposed to the actual
stress of the job.
Publication bias: yes,
this study w

as m
ost

likely published due
to the positive
findings that a
residency program

can possibly influence
new

nurse retention.

C
lipper &

C

herry
(2015)

quantitative/
descriptive,
com

parative

59 participants/
gender and ethnicity
w

ere not specified

Purpose: to describe
the im

plem
entation

and evaluation of a
preceptor
developm

ent program

and its effect on the
new

graduate nurse’s
transition to practice
and m

easure first-
year turnover.
A

im
s: to assess new

nurses’ perceptions
of their transition and
preceptors betw

een 2
groups of preceptors
(one group trained in
a structured and w

ell-
developed program

:
details w

ell
explained, and the
other group w

as
untrained).
V

ariables: ID
: new

nurses w

ithin the first
year of hire. D

V
:

perceptions of
transition to practice
betw

een 2 groups of
preceptors. T

rained

T
he study evaluated

the effectiveness of
a preceptor program

by m

easuring
perceptions of
transition to practice
and 1

st year
retention of 2
groups of form

er
nurse graduates and
the other group w

as
those that did not
participate in
structured training.
N

ew
graduates have

m
ore positive

perceptions
regarding safe care
giving and have a
slightly better
retention rate than
those w

ho did not
have a structured
new

graduate
program

.
Preceptors need to
address them

es of
socialization
(protective factors

+
+




R

isk of bias: Possible
lim

itations in the
design – obviously
w

ell-trained
preceptors w

ould
better understand the
needs of new

nurses
and help m

itigate the
stress of transition,
but the study did not
reveal reasons for
consistent turnover or
new

nurse
dissatisfaction during
the first year of hire.
It w

as clear from

previous literature
that a w

ell prepared
and trained preceptor
w

ill decrease
transition shock, but
still not a big change
in new

nurse
retention.
Inconsistency: the
findings w

ere
consistent w

ith the

preceptors and
untrained preceptors.
Instrum

ents: 16-item

investigator
developed surveyed
based on the
attributes of
transition shock
theory w

as used to
obtain data regarding
new

nurse
perceptions of the
transition process and
the effectiveness of
their preceptors.

in resiliency) in
order to build
confidence and
foster good
relationships to
build form

s of
support.
N

ew
nurses that had

trained preceptors
expedited to a
higher level of
practice faster than
the untrained
preceptor cohort.
It w

as anticipated
that those that w

ere
in the cohort of
untrained preceptor
w

ould stay at the
organization due to
lack of confidence
and that w

as not the
case.
C

onfidence w
as

found to directly
im

pact patient
outcom

es positively
and increase w

hen
new

nurses had a
good relationship

phenom
enon of new

nurses during the first
year of hire.
Indirectness:
inform

ation in this
study w

as not very
applicable to
understanding new

nurse turnover or how

transition shock
m

itigation strategies
can decrease turnover.
Im

precision:
inadequate am

ount of
data regarding new

nurse confidence, the
support a new

nurse
receives, and the
intention to leave first
job.
Publication bias: N

ot
found. T

he Journal of
C

ontinuing E
ducation

in N
ursing publishes

m
any types of studies

that reveal positive
and negative findings
such as this study.

w
ith his or her

preceptor. T
his also

w
as correlated w

ith
the new

nurse
having a safer
practice than those
w

ith an ineffective
preceptor.

Fiedler et al.
(2014)

quantitative/
descriptive

51 new
nurses in a

residency program

(m
ost w

ere second
degree students) on
diverse units/ m

edical
center in the M

idw
est,

a U
H

C
/A

A
C

N

program
. G

ender and
ethnicity of participants
w

ere not specified.

Purpose: to determ
ine

w
hat influence a

nurse residency
program

has on long-
term

outcom
es

including turnover,
career satisfaction,
and leadership
developm

ent. A
im

s:
1. describe the long-
term

(beyond the 1st
year of em

ploym
ent)

turnover rates of N
R

P
graduates, 2. exam

ine
the long-term

career
satisfaction of
N

R
P graduates

beyond the 1st year
of em

ploym
ent,

and 3. explore long-
term

leadership
developm

ent
of N

R
P graduates

beyond the 1st year
of em

ploym
ent.

T
he long-term

outcom

es of a nurse
residency program

have benefits to the
organization and
individual turnover
rates low

er than the
national average of
14.7%

(1.5-3 years
after the residency
program

.
T

he literature
review

in this study
points out that
w

ithin 6 m
onths,

residents noticed
decrease job
satisfaction, yet at
the end of the year,
significant increase
in satisfaction
resulted. Support
(protective factor of
resiliency) from

the

+
+




R

isk of bias:
D

etected. U
sing one

instrum
ent, w

hich
m

easures satisfaction
to evaluate turnover
lim

ited the execution
of the study and other
data or qualitative
factors w

ere m
issed

for reasons or
intentions to leave.
Inconsistency:
D

etected. Sam
ple size

w
as sm

all, it w
as

diverse yet getting in
touch w

ith
participants that have
left but filled out the
survey w

as difficult
and possibly lead to
inconsistencies w

ith
results.

V
ariables: IV

: A
A

C
N

residency program

.
D

V
’s: career

satisfaction,
leadership
developm

ent,
hospital com

m
ittee

involvem
ent,

certification status,
pursing an advanced
degree.
Instrum

ents:
M

cC
loskey/M

ueller
Satisfaction Scale
(M

M
SS) has 8

subscales: extrinsic
rew

ards, scheduling
satisfaction,
fam

ily/w
ork balance,

cow
orkers,

opportunities
for social contacts,
professional
responsibilities,
praise/
recognition, and
control/responsibility.

organization,
m

anagers, and
recognition leads to
satisfaction and w

ell
as good collegial
relationships.
Peer support w

as
ranked as a m

ajor
com

ponent of
nurses’ job
satisfaction.

Indirectness: N
one

detected as the
applicability is
reasonable as
residency program

s
are supportive and
foster new

nurses’
careers, therefore
increased retention is
very probable.
Im

precision:
D

etected.
D

issatisfaction results
in turnover yet the
tool w

as m
easuring

satisfaction and that
w

as assum
ed the

reason for turnover,
m

ore investigation
regarding w

hat led to
dissatisfaction w

ould
have been m

ore
helpful in
understanding if a
residency program

,
over years, affects
retention rates alone.
Publication bias: N

ot
detected. T

he Journal
of N

ursing
A

dm
inistration

publishes pilot studies
w

ith negative results

and also larger sam
ple

sizes.

Fink et al.
(2008)

m
ixed m

ethod/
sequential
exploratory

434 graduate nurse
residents in the
U

niversity
H

ealthSystem

C
onsortium

/A
A

C
N

nurse residency
program

at 12
academ

ic hospital sites.
G

ender and ethnicity of
participants w

as not
specified.

Purpose: T
o evaluate

if qualitative
responses to C

asey-
Fink G

raduate N
urse

E
xperience Survey

could be analyzed
quantitatively to
easily analyze new

nurses’ experiences
during a post B

SN

nurses residency
program

.
A

im
s: 1. to analyze

the qualitative voices
of the
resident respondents
to determ

ine if
com

m
ents could

further enrich the
quantitative data and
2. to determ

ine if
analysis of the
them

es m
ined from

the qualitative data
could be used to
convert the open-
ended questions on
the C

asey-Fink
G

raduate N
urse

E
xperience Survey

“T
he results of this

qualitative analysis
perm

itted further
revisions of the
C

asey-Fink
G

raduate N
urse

E
xperience Survey.

T
hem

es identified
from

data analysis
of the 3 top skills
difficult to m

aster at
each period, and the
5 open-ended
questions asked on
the original survey,
w

ere of sufficient
strength to convert
these item

s to
m

ultiple-choice
form

at. T
he one

open-ended item

that the authors
retained w

as
the final survey
question that asked
residents to
com

m
ent on their

experiences”
(p.347). N

ew
nurse

stressors w
ere

+
+




M

ethodical
lim

itations: D
etected.

T
he design and

execution of the study
w

as to use a
quantitative tool to
gather qualitative data
and revision of the
tool w

as suggested.
R

elevance: T
he body

of evidence from

prim
ary studies

supported review

findings that is
applicable to the
context specified in
the review

questions.
C

oherence: T
here is a

clear fit betw
een the

data from
prim

ary
studies and the review

findings, yet the
sam

ple is
hom

ogeneous,
dow

ngraded 1 point.
A

dequacy of data:
T

here is a good

into quantitative
questions for ease of
test adm

inistration
and analytic
procedures.
V

ariables: D
V

s: role
changes, lack of
confidence,
w

orkload, fears,
orientation issues. IV

:
residency program

w

ithin the first year
of hire.
Instrum

ents: C
asey-

Fink G
raduate N

urse
E

xperience Survey.
Q

ualitative data
outcom

es w
ere

gathered via open
ended questions from

the author.

issues w
ith skills

over a period of
tim

e, they w
ere not

getting easier. T
his

w
as attributed to

constant preceptor
assistance and lack
of being able to
perform

skills
independently
during com

plex
patient cases.
W

ork/life balance
w

as a m
ajor stressor

and im
pacted the

ability to function at
the job.
B

eing able to
com

m
unicate w

ith
M

D
s (a protective

factor of resiliency)
and organize their
w

orkload w
ere

barriers to
transitioning into
their new

role w
hich

reflected K
ram

er et
al. (2013) and
H

alfer and G
raf’s

(2006) results.

am
ount of qualitative

data to represent the
hom

ogeneity sam
ple.

Publication bias: N
ot

detected. T
he Journal

of N
ursing

A
dm

inistration
publishes pilot studies
w

ith negative results
and also larger sam

ple
sizes.
Q

uality increased by
1 point due to all
plausible residual
confounding factors
dem

onstrated an
effect.

C
om

m
unication

from
m

anagem
ent

and the desire to be
a part of the unit’s
culture w

ere pointed
out to be a m

uch-
needed support.
T

he top 3 m
ost

satisfying aspects of
graduate nurse
residents’ w

ork
environm

ent
included as follow

s:
support,
cam

araderie,
and caring for
patients.
“T

here is not
enough socialization
in the residency
program

. B
ecom

ing
a new

nurse in a
new

environm
ent is

difficult’’ (p.347).

G
ill et al.

(2010)
cohort study using
m

ixed m
ethods/

sequential
exploratory

7 participants/ inpatient
care areas at L

evel 1
traum

a center. 7.7%

participants w
ere m

ale.
T

he ethnicity of

Purpose: to
investigate the
expectations,
perceptions, and
satisfaction of
graduate nurses after

N
ew

graduates are
fairly satisfied. T

w
o

them
es em

erged:
establishing
relationships and
learning the job.

+
+




M

ethodical
lim

itations: N
ot

detected as the

participants w
as not

specified.
6 and 12 m

onths of
em

ploym
ent.

A
im

s: to describe
new

graduates during
the first year of
practice.
V

ariables: D
V

:
perceptions regarding
the first year of
practice such as
social support, stress,
professional values
Instrum

ents: 10-item

abbreviated version
of the N

ational
D

atabase of N
ursing

Q
uality Indicators

(N
D

N
Q

I) revised
survey for R

N
s w

hich
is a series of
statem

ents relating to
the nurses’
perceptions of their
w

ork. It has been
show

n to be both
reliable. “A

t the
com

pletion of the
final interview

,
graduate nurses w

ere
asked to com

plete a
brief three-item

survey on intent to
leave. Individuals

Strong tie to
prim

ary studies that
states group
cohesion (a
protective factor of
resiliency) and
satisfaction can
increase the ability
to stay at one’s job
and in nursing.
A

t the end of the
12-m

onth study,
m

any graduates
considered leaving
their until and the
organization, but
few

participants
thought of leaving
the profession
entirely.

prim
ary studies are

reflected in the review

findings.
R

elevance: T
he study

w
as relevant. T

he
body of evidence
from

prim
ary studies

supported the review

finding and is
applicable to the
context of new

nurse
graduates and the
aim

s of the study.
C

oherence: T
he study

w
as coherent, and the

findings w
ere a fit

betw
een the prim

ary
studies and the review

finding.
A

dequacy of data:
T

here w
as adequate

data supporting the
review

finding but the
sam

ple w
as very

sm
all.

Publication bias:
T

here is no detection
of publication bias as
results revealed
perceptions and w

ere
not deem

ed as
positive or negative.

w
ere asked to

indicate how
often

they contem
plated

leaving their unit, the
organization, or the
profession of nursing
on a 5-point L

ikert
scale” (p. E

13).

H
odges et

al. (2008)
qualitative:
phenom

enological
m

odel/
exploratory

11 new
nurses/

southeastern U
S and

had experience
betw

een 12 and 18
m

onths. 9%
of

participants w
ere m

ale.
T

he ethnicity of
participants w

as not
specified.

Purpose: T
o explore

the nature of
professional
resilience in new

B

SN
nurses in the

acute care setting and
to extrapolate
pedagogical
strategies that can be
developed to support
resilience and career
longevity.
A

im
s: to explore the

existence and social
structure of
professional
resilience am

ong
practicing nurses to
evolve a m

iddle
range theory to
explain the
relationships of
constructs w

ithin the
concept.

N
ew

nurses spend a
significant am

ount
of tim

e learning
their place in the
social structure and
need positive
experiences to feel
they are a part of the
w

ork environm
ent.

R
esilience is needed

to ensure new
nurse

self-protection, risk
taking, and m

oving
forw

ard w
ith

reflective
know

ledge of self.
T

hem
es that

em
erged w

ere
learning the m

ilieu
(developing
confidence and
skills), discerning fit
(accepted by the
culture), and

+
+




M

ethodical
lim

itations: N
ot

detected as prim
ary

studies revealed
sim

ilar findings.
R

elevance: the study
is relevant due to its
context to the aim

w

hich explored
professional resilience
and as a protective
factor, social support.
C

oherence: it is clear
that social support is
needed to be
professionally
resilient, yet it w

as
not coherent
regarding how

to
garner social support
to ensure the

V
ariables: D

V
:

experiences of social
support of new

nurses.
Instrum

ents: open-
ended questions

m
oving through

(recovering from

stress and
identifying those
they can trust in
order to develop
protective factors
against w

ork-life
issues).
Participants noted
significant am

ount
of adapting that
m

ust take place to
be accepted socially
and also the
disparity betw

een
academ

ics and
practice. T

his
distressed new

nurses as they
actualized the
discrepancies.
N

ew
nurses’

em
otional energy is

consum
ed by

cognitive w
ork;

resilience is
necessary for such
w

ork in order to
grow

from

adversity.

developm
ent of

resiliency,
dow

ngraded a point.
A

dequacy of data:
T

here is an adequate
am

ount of data but is
from

a sm
all sam

ple
yet does reflect
current findings
regarding the
phenom

enon of new

nurse resilience.
Publication bias:
T

here is no detection
of publication bias as
results revealed
perceptions and w

ere
not deem

ed as
positive or negative.

C
onstruction of a

new
nurse’s social

identity w
as found

to be im
portant to

create their
professional
identity.

H
odges et

al. (2010)
qualitative:
grounded theory/
descriptive

19 new
and

experienced B
SN

nurses w

orking in
direct patient care (9
participants w

ere 11 to
18 m

onths in
practice)/southeast U

S-
m

ultiple levels of m
ed

centers and hospitals.
N

o gender or ethnicity
of participants w

ere
specified.

Purpose: to explain
how

B
SN

acute care
nurses understand,
adapt to, and
negotiate challenge
and change in acute
care settings in the
context of social and
structural features
and career
persistence.
A

im
s: to understand

career persistence in
B

SN
acute care

nurses and create a
m

iddle range theory
to place into practice
to encourage career
resilience.
V

ariables: nurses
spanning 11 m

onths –
over 5 years.
Instrum

ents: open-
ended questions

T
he central them

e
w

as building
professional
resilience, w

as
noted to be the
central social
process.
V

erifying fit:
participants stated
incongruent
personal principles
and values
regarding nursing
practice and
incom

patibility w
ith

the environm
ent

(the environm
ent

does not m
atch their

strengths).
Stage setting: how

to protect one’s self
and form

relationships in

+
+




M

ethodical
lim

itations: D
etected

as the studied w
as

com
posed of new

nurses (w

ithin 11-18
m

onths of practice to
those w

ith 5 or m
ore

years). T
hat is a large

breath of experience
to find out about
nurse’s resilience as
the stress of a new

job
tests one’s resilience
and those that have
overcom

e adversity
are know

n as
resilient. D

ow
ngraded

one point.
R

elevance: G
ood

relevance as the
concept of an ever-
changing health care

order to feel secure
and supported
(protective factors
of resiliency).
O

ptim
izing the

environm
ent:

seeking activities
that help one attain
professional goals.
T

he key to
understanding
professionalism

of
nurses is to
understand one’s
social group.

arena is obvious,
career resilience is a
characteristic one
needs to stay in the
career.
C

oherence: T
he data

aligns to the prim
ary

studies.
A

dequacy of data:
T

he data is com
ing

from
a sm

all
population of
different ages and
tim

e fram
es w

ithin
their careers (18
m

onths to over 5
years), dow

ngraded
one point.
Publication bias:
M

ost likely this study
w

as published
because of its
“sensibility”
regarding
recom

m
endations to

help nurses stay
engaged w

ith their
w

ork life and w
ork

environm
ent,

dow
ngraded one

point.

K
ram

er et
al. (2012)

qualitative:
grounded theory/
exploratory

82 participant
interview

s w
ere done.

A
t the tim

e of
interview

ing, 71%
(n =

236) of the 330 N
L

N
s

w
ere betw

een 9 and 12
m

onths post hire/local
M

agnet hospitals.
G

ender and ethnicity of
participants w

ere not
specified.

Purpose: to elicit
from

new
nurses and

experienced nurses
on clinical units w

ith
very healthy w

ork
environm

ents, the
com

ponents and
strategies of nurse
residency program

s
and effective in new

nurse integration into
professional practice.
A

im
s: W

hat N
R

P
com

ponents and
strategies do N

L
N

s
and clinical nurses
practicing on clinical
units w

ith V
ery

H
ealthy W

ork
E

nvironm
ents

(V
H

W
E

) identify as
effective in N

L
N

transitioning and
integrating into
professional practice?
V

ariables: D
V

s:
delegation,
prioritization, conflict
resolution w

ere used
to construct the
interview

schedule
and as the basis for
selection of

First them
e w

as
about delegation.
Second them

e w
as

about prioritization.
T

hird them
e w

as
about getting w

ork
done. Fourth them

e
clinical autonom

y
and how

to m
ake

the right decisions.
T

ext m
essages to

M
D

s to relay info
and data w

as citing
as an effective
com

m
unication

technique in
hospitals. Fifth
them

e: constructive
conflict resolution.
Sixth: feedback to
restore self-
confidence (a
protective factor of
resiliency).
R

esults of this study
support the
recom

m
endation

that developm
ent of

tw
o-stage,

T
ransition plus

Integration, N
R

Ps
are no longer an

+
+




M

ethodical
lim

itations: D
etected.

Interview
s w

ere
conducted w

ith 2 or 4
new

nurses and
experienced nurses
(contam

ination
possible as responses
m

ay not have been as
genuine if nurses
w

ere alone) in each of
the units and w

ere
interview

ed by
various hospital unit
educators. D

ecreased
one point.
R

elevance: V
ery

relevant as learning
about w

hat creates a
healthy w

ork
environm

ent can help
prepare a strong
w

orkforce and good
transition experience
is very desirable for
organizations.
C

oherence: Som
e

hospitals had clinical
coaches and others
did not, this m

ay have

participant
observations.
Instrum

ents: open-
ended questions

option but a
necessity. T

hese
N

R
Ps need to have

clearly
differentiated goals,
com

ponents,
expected role
perform

ance, and
rites of passage.

affected participants’
responses and
experiences lim

iting
generalizability yet
since all program

s
w

ere enrolled at
hospitals w

ith
residency program

s
greater than 3 years,
and since not every
hospital has coaches,
the sam

ple size w
as

large enough to
represent the
population of those in
residency program

s.
A

dequacy of data:
T

here is adequate data
to support the finding
that residency
program

s are
preferred w

hen
transitioning to first
year of practice.
Publication bias:
findings w

ere not
positive or negative,
therefore none
detected.

L
i et al.

(2014)
quantitative,
correlational/
descriptive,

A
convenience sam

ple
of 251 nurse residents
(0-3 m

onths of w
orking

Purpose: T
he purpose

of the study
exam

ined protective

“O
rganizational

com
m

itm
ent

+
+




predictive

on a pediatric unit in
L

os A
ngeles, C

A
).

7.9%
of participants

w
ere m

ale. Percentage
of C

aucasian
participants 30.3%

,
B

lack 0.8%
, L

atino
2.4%

, and other
ethnicities w

ere not
reported.

factors that m
ay

decrease burnout and
increase job
satisfaction in a nurse
residency program

over 3 m

onths. G
roup

cohesion optim
izes

practice w
hereas

organizational
com

m
itm

ent helps to
create an intention to
stay at current job (p.
96).
A

im
: to determ

ine
w

hether factors such
as group cohesion
and organizational
com

m
itm

ent w
ould

be protective and
m

oderate the
association betw

een
stress exposure and
posttraum

atic stress
sym

ptom
s and other

negative nurse
outcom

es w
hich

w
ould create positive

ones.
V

ariables: D
V

s:
stress, com

passion,
satisfaction, group
cohesion, and

w
as not found to

protect nurse
residents from

negative nurse
outcom

es, it did
play an im

portant
role in prom

oting
job satisfaction” (p.
95). “R

esults
confirm

ed previous
findings that stress
exposure and PT

SD

sym
ptom

s have
serious im

plications
for a range of
affective outcom

es
for new

resident
nurses” (p. 95).
Inform

ation w
as

provided about the
relationships that
group cohesion and
negative nurse
outcom

es have and
that establishing a
relationship in a
group can serve as a
protective factor in
helping bounce
back from

negative
nurse outcom

es like
burnout and
com

passion fatigue.

R
isk of bias: sam

ple
bias due to
convenience sam

pling
and collection of
inform

ation w
as not

reliable and only at
one hospital, one type
of floor.
Inconsistency:
findings w

ere
consistent w

ith other
findings w

ithin the
context of group
social support
decreases the adverse
effects of stress.
Indirectness: Findings
w

ere applicable to the
context of the study.
Im

precision: relevant
only to one hospital
on one floor,
dow

ngraded one
point.
Publication bias: not
likely as findings
w

ere neither positive
or negative.

organization
com

m
itm

ent.
Instrum

ents: L
ife

E
vents C

hecklist
good reliability,
PT

SD
C

hecklist
C

ivilian V
ersion,

C
om

passion
Satisfaction and
Fatigue T

est, N
urse

Job Satisfaction
Scale, G

roup
C

ohesion Scale, and
O

rganizational
C

om
m

itm
ent Scale

**Social support
could also im

pact
how

nurses respond
to stress (p. 97).

M
artin &

W

ilson
(2011)

qualitative/
interpretive
phenom

enology,
descriptive

7 new
nurses w

ithin the
first year of practice
w

ho participated in an
intensive transition
program

designed as a
com

ponent of an
orientation program

to
ease new

graduates into
nursing practice on
various
m

edical/surgical units/
purposive convenience
sam

ple. 14%
of

participants w
ere m

ale.
Percentage of
C

aucasian participants
w

as 85.7%
, B

lack

Purpose: to exam
ine

the lived experience
of new

ly licensed
R

N
s in their first year

of practice in a
hospital setting.
A

im
s: to extract the

m
eaning and

understand from
the

hum
an experience,

new
nurses, during

their first year of hire.
V

ariables: D
V

:
experiences of new

nurses during their
first year of hire.

T
hem

es: real nurse
w

ork, guidance,
transitional
processes,
institutional context,
and interpersonal
dynam

ics. “T
he

cum
ulative effects

of socialization,
skill acquisition,
and stress on new

nurses indicate that
research is needed
to answ

er questions
regarding
recruitm

ent,
retention, and job

+
+




M

ethodical
lim

itations: som
ew

hat
detected as
convenience sam

ple
w

as used to recruit
sam

ple yet fram
ew

ork
for the study m

atched
the purpose and aim

s
for this study.
R

elevance: the
findings are very
applicable to the
context of new

nurse
experiences.

14%
, there w

ere no
other ethnicities
reported.
(purposive: the
researcher deliberately
selects subjects m

ost
know

ledgeable about
the issue under study.)

Instrum
ents:

interview
questions

satisfaction” (p. 21).
C

aring of the
profession vs non-
caring w

ithin the
profession is posed
as an argum

ent for a
new

orientation
objective – possibly
the form

ation of a
“caring group”
(better know

n as
support group).
“Professional
acculturation is a
com

plex process
that requires tim

e to
navigate. T

he
success of the
process is often
dependent upon the
degree of perceived
support the new

ly
licensed R

N

receives” (p.22).
R

elationships are
required to adapt to
the stress of starting
nursing. C

ollegial
relationships w

ith
all nursing staff and
M

D
s, and ancillary

staff m
atters to new

nurses.

C
oherence: good

coherence w
ith

previous studies of
professional
acculturation and
struggle to create a
professional identity
w

hile transitioning to
practice w

hich is
deem

s extrem
ely

stressful.
A

dequacy of data:
findings aligned w

ith
K

ram
er’s sem

inal
w

ork (1974), R
eality

Shock, and
reconfirm

ed via
D

uchscher’s w
ork on

Transition Shock
Theory.
Publication bias: none
detected as the study
did not report positive
or negative findings.

M

cC
alla-

G
raham

&

D
e G

agne
(2015)

qualitative:
phenom

enological/
exploratory

10 participants, using a
purposive, snow

ball
sam

pling/southw
est

Florida, m
ost w

ere
experiencing their
second career. G

ender
and ethnicity w

ere not
specified.

Purpose: to explore
the lived experiences
of new

graduate
nurses em

ployed in
an acute care setting.
A

im
s: to best

understand new

graduate nurses’
experiences in the
acute setting
V

ariables: D
V

: acute
care setting in the
first year of hire.
Instrum

ents: 11 open-
ended questions

Participants stated
that nursing school
did not prepare
them

for current
roles or
responsibilities and
that the goal of
nursing school w

as
only to assist the
new

grad in passing
the N

C
L

E
X

. “T
he

findings suggest
that the graduate
nurses thought that
if they developed
good coping skills,
the acute care
clinical setting
m

ight be less
stressful for them


(p. 125).
Participants also
stated they w

ere
very overw

helm
ed

by the w
orkload and

that positive
reinforcem

ent
helped m

itigate this
stress.

+
+




M

ethodical
lim

itations: none
detected as the
findings reflected
sim

ilar findings as
prim

ary studies, there
w

ere very little issues,
other the sam

pling
m

ethod, in the w
ay

the study w
as

designed/
conducted.
R

elevance: the
findings w

ere relevant
and the extent of the
body of evidence
from

the prim
ary

studies supported and
is applicable to the
context of the new

nurse shortage
phenom

enon
occurring w

ithin the
first year of practice.
C

oherence: T
he

researchers discussed
a clear fit betw

een the
data from

prim
ary

studies and the review

findings.
A

dequacy of data:
there w

as rich data
and the am

ount to
support the findings
w

ere adequate.
Publication bias: none
detected as the results
are neither positive or
negative influencing
the preference to
publish.

O
lson

(2009)
qualitative/
exploratory,
interpretive,
phenom

enological,
longitudinal

12 participants/
purposive sam

ple of 2
groups of new

graduates: 6 B

SN
and 6

A
D

N
nurses – full tim

e
staff nurses at the tim

e
of data collection.
16.6%

of participants
w

ere m
ale. E

thnicity of
participants not
specified.

Purpose: to
understand the
experience of new

ly
licensed nurses from

their perspective.
A

im
s: to understand

m
illennial, novice

nurses’ experiences
throughout the first
year of practice
V

ariables: D
V

: new

nurse experiences
Instrum

ents: open
ended interview

s at 3,
6, and 12 m

onths

T
hem

es that
em

erged: being in
unfam

iliar
surroundings w

hich
seem

ed confusing
and overw

helm
ing

because they had
spent lim

ited tim
e in

acute care as
students. A

fter a
year, participants
expressed fear about
being oriented to a
different place. T

he
second them

e, “out
of the blue,” w

hich
are the “never to be
forgotten”
experiences – so

+
+




M

ethodical
lim

itations: lim
itation

regarding sm
all

sam
ple yet findings

w
ere analyzed w

ell,
and researcher
dem

onstrated a good
ability to reflect on
participants’
experiences to create
com

m
on them

es that
are applicable to the
phenom

enon of new

graduate experiences.
R

elevance: Prim
ary

studies support the

chaotic and the
difficulty of trying
to keep up – this
w

as relayed to
researchers as
feelings of
helplessness, guilt,
and extrem

e sadness
as novices coped
w

ith death or a
m

edical error for the
first tim

e. T
he third

them
e: finding m

y
voice, this w

as a
description of
novices’
relationships w

ith
preceptors, M

D
s,

and other staff
m

em
bers. Feeling

w
elcom

ed and
confronting
incivility w

ith other
nurses w

ere crucial
to feeling successful
in the transition.
T

he fourth them
e

w
as “am

I ok?”
O

btaining feedback,
trust w

ith know
ing

som
eone w

ould tell
them

they w
ere

doing som
ething

findings and it is
applicable to
m

illennial, novice
nurses’ and their
intentions to do
everything really w

ell
regardless of how

foreign som

ething is
and the need for
im

m
ediate attention

and feedback to
continually grow

and
learn.
C

oherence: there is a
good fit betw

een the
prim

ary studies and
the findings in this
study.
A

dequacy of data: the
quantity and degree of
richness in prim

ary
studies support the
review

findings.
Publication bias:
D

oubtful due to
neither positive or
negative results w

ere
shared, only reported
experiences of a
sam

ple of new
nurses.

w
rong w

as very
im

portant to
participants as they
expressed great
anxiety regarding
m

aking m
istakes.

T
he acute setting is

very unfam
iliar, and

socialization can
assist w

ith the
stressful adjustm

ent
w

hich m
akes it

difficult to grow
and

continue to learn.
M

illennials w
ant

nurturing, attention,
and continuous
feedback w

hich
places an extensive
value on social
support (a
protective factor of
resiliency).

Pellico et al.
(2009)

qualitative: case
study m

odel/
descriptive

612 participants in 12-
18 m

onths of practice
/stratified sam

pling in
m

etropolitan m
idsize

areas in the U
S

w
orking inpatient.

E
thnicity and gender of

participants not
specified.

Purpose: “T
he

purpose of this article
w

as to explore the
perceptions of 612
N

L
N

s’ nascent
experiences as
reflected in their
com

m
ents provided

in a national survey

“5 them
es w

ere
discovered.
“C

olliding
expectations”
describes conflicts
betw

een nurses’
personal view

of
nursing and their

+
+




M

ethodical
lim

itations: this w
as

secondary findings
from

a parent study
and there w

ere no
lim

itations in the

that sought to gain a
better understanding
of the w

ork life of
N

L
N

s” (p. 194).
A

im
s: to understand

N
L

N
’s w

ork-life
experiences.
V

ariables: m
ultiple

areas across the U
S

Instrum
ents: 16-page

survey w
ith 207

item
s.

lived experience.
“T

he need for
speed” describes the
pressure related to a
variety of tem

poral
issues. “Y

ou w
ant

too m
uch”

expresses the
pressure and stress
N

L
N

s feel
personally and
professionally.
“H

ow
dare you”

describes
unacceptable
com

m
unication

patterns betw
een

providers. “C
hange

is on the horizon”
suggests optim

ism

for the future as
N

L
N

s speak of
transform

ing the
system

s w
here care

is provided (a
protective factor of
resiliency). T

his
content analysis
reveals that the
w

orking
environm

ent w
here

N
L

N
s begin their

design of the findings
of the prim

ary
studies.
R

elevance: the
findings are
applicable to the
context specified to
explore perceptions of
new

nurses’ w
ork life.

C
oherence: T

here is a
good fit betw

een the
data from

the prim
ary

studies and the
findings yet prim

ary
studies did not reveal
any m

ention of
w

anting to change
new

nurses’
experiences as stated
in the review

of
findings in this study.
A

dequacy of data: the
data underlying a
review

finding are
rich and com

e from

different num
bers of

participants per study.
Publication bias:
doubtful as the results
w

ere neither positive
or negative but
reported the

career is in need of
reform

” (p. 194).
experiences of
participants.

N
ote. N

L
N

= new
ly licensed nurse; ⨁



=
high; ⨁



=
m

oderate; ⨁


=
low

; ⨁


= very low
; +

+
=

observational
design; +

+
+

+
=

experim
ental study.

T
able C

Tools U

sed in Studies to D
eterm

ine N
LN

R
esiliency or P

rotective F
actors of R

esiliency
Study

T
ool

N
L

N
O

utcom
es R

eflecting N
L

N
R

esiliency
A

nderson,
L

inden,
A

llen, &

G
ibbs (2009)

T
he H

alfer-G
raf Survey (validity/reliability not reported)

(H
alfer &

G
raf, 2006) and open-ended questions

C
om

pared job satisfaction and em
ployee

engagem
ent after com

pleted 2-day interactive
residency m

odules w
hich assisted N

L
N

s to perform

job, identify resources, and job expectations.
M

ost valuable strategy to satisfy N
L

N
s w

as em
ail

com
m

unication as a form
of support, follow

ed by
positive patient outcom

es and team
w

ork.

B
ontrager,

H
art, &

M

areno
(2016)

Preceptor R
ole E

ffectiveness Scale (reliability coefficient =
.75) (R

auen, 1974); G
roup C

ohesion Scale (reliability
coefficient = .81) (H

inshaw
&

A
tw

ood, 1983); N
urse Job

Satisfaction Scale (overall internal consistency reliability
coefficient = .88) (H

inshaw
&

A
tw

ood, 1983); and Intent to
Stay Scale (reliability coefficient = .85) (K

im
, Price,

M
ueller, &

W
atson, 1996)

Preceptors, job satisfaction, and group cohesion
w

ere found to be im
portant to reduce transition

shock and intention to leave.

C
lark &

Springer
(2012)

O
pen-ended questions

L
earning the w

ork flow
, feeling valued, preceptors,

and cow
orkers enhanced satisfaction and

com
m

itm
ent to the profession and the ability to w

ork
in a team

.

C
line et al.

(2017)
C

asey-Fink G
raduate N

urse E
xperience Survey: the section

on com
fort and confidence (C

ronbach
= .78). T

he next
section consists of 5 factors, nam

ely, support (
= .90),

patient safety (
= .79), stress (

= .71),
com

m
unication/leadership (

= .75), and professional

A
custom

ized residency program
m

ay im
prove

N
L

N
s’ experiences as they enter practice w

hich
increases confidence and m

ay lead to intention to
stay at current job.

satisfaction (
= .83) (C

asey, Fink, K
rugm

an, &
Propst,

2004) and institutional retention m
etrics

C
lipper &

C

herry
(2015)

16-item
investigator developed survey assessing the

attributes of transition shock to obtain N
L

N
perceptions and

effectiveness of their preceptors (C
ronbach

= .954)
(D

uchscher, 2009)

N
L

N
s w

ere m
ore positive regarding practices and a

slightly better retention rate w
hen a structured

preceptor program
w

as provided.

Fiedler, et al.
(2014)

M
cC

loskey/M
ueller Satisfaction Scale (C

ronbach
= .94)

(M
ueller &

M
cC

loskey, 1990)
R

esidency program
s can low

er turnover rates yet at
6 m

onths, job dissatisfaction decreased yet at 12
m

onths satisfaction increased.

Fink et al.
(2008)

C
asey-Fink G

raduate N
urse E

xperience Survey (C
ronbach

= .89) (C
asey et al., 2004) and open-ended questions

C
onstant preceptor assistance increased N

L
N

satisfaction.

G
ill, D

eagan
&

M
cN

ett
(2010)

10-item
abbreviated version of the N

ational D
atabase of

N
ursing Q

uality Indicators (reliability coefficient = .91)
(T

aunton et al., 2004) and open-ended questions

E
stablishing relationships and learning the job

positively affected N
L

N
satisfaction. D

espite
positive results, som

e N
L

N
s considered leaving the

organization but few
stated they thought of leaving

the profession.

H
odges,

K
eeley, &

T

royan
(2008)

open-ended questions
D

eveloping confidence by learning skills, being
accepted by others, and recovering from

stress
because of the academ

ic/practice disparity w
as

found im
portant for N

L
N

s to build professional
identities and a social connection in order to adapt
and negotiate career stress.

H
odges,

T
royan, &

K

eeley
(2010)

open-ended questions
T

he practice environm
ent does not m

atch N
L

N

strengths. Feeling supported is key and establishing
a social group is necessary to develop career
persistence.

K
ram

er et al.
(2013)

open-ended questions
D

elegation, prioritization, accom
plishing w

ork,
clinical autonom

y, effective clinical decision-

m
aking, constructive conflict resolution, and

restoring self-confidence are im
portant factors to

prom
ote N

L
N

professional practice.

L
i et al.

(2014)
L

ife E
vents C

hecklist (reliability
> .50, test-retest

reliability r = .82) (G
ray, L

itz, H
su, &

L
om

bardo, 2004),
PT

SD
C

ivilian C
hecklist (internal consistency

= .94, test-
retest reliability r = .88) (W

eathers, L
itz, H

uska, &
K

eane,
1991), C

om
passion Satisfaction and Fatigue T

est (test
produces three subscales: com

passion satisfaction, burnout,
and C

F/ST
S. E

ach scale show
s good internal consistency in

this sam
ple (α = .87, .90, and .87) (Stam

m
, 2002), N

urse Job
Satisfaction Scale (

= .90) (M
ueller &

M
cC

loskey, 1990),
G

roup C
ohesion Scale (

= .89) (B
yrne &

N
elson, 1965),

and O
rganizational C

om
m

itm
ent Scale (

= .89) (Porter,
Steers, M

ow
day, &

B
oulian, 1974)

R
elationships and social support can buffer stress

and com
passion fatigue.

M
artin &

W

ilson
(2011)

open-ended questions
Socialization, the ability to perform

skills, and
collegial relationships help to garner job satisfaction
and retain N

L
N

s.

M
cC

alla-
G

raham
&

D
e

G
agne (2015)

open-ended questions
N

L
N

s reported m
ore training needed for coping

skills to deal w
ith stress.

O

lson (2009)
open-ended questions

T
he overw

helm
ing w

ork atm
osphere confused N

L
N

s
as w

ell as new
experiences not encountered w

hile in
nursing school translated into feelings of
helplessness. Inabilities to speak w

ith M
D

s and not
know

ing w
ho to trust verified extensive social

support and continuous feedback are needed in
m

illennial N
L

N
s the first year of hire.

Pellico,
B

rew
er, &

K

ovner
(2009)

open-ended questions
Poorly understood N

L
N

expectations, the
expectations for N

L
N

s to perform
quickly, and

incivility am
ong clinicians inform

s organizations
and leaders that the w

ork environm
ent needs reform

.
N

ote. N
L

N
= N

ew
ly licensed nurse.

R
eproduced w

ith perm
ission of copyright ow

ner. F
urther reproduction prohibited w

ithout perm
ission.

RESEARCH ARTICLE

Workplace bullying, psychological hardiness,
and accidents and injuries in nursing: A
moderated mediation model
Stephen T. T. TeoID

1*, Diep Nguyen1, Fiona Trevelyan2, Felicity Lamm3, Mark Boocock4

1 School of Business and Law, Edith Cowan University, Western Australia, Australia, 2 School of Clinical
Sciences, Auckland University of Technology, Auckland, New Zealand, 3 The Centre for Occupational Health
and Safety Research, Auckland University of Technology, Auckland, New Zealand, 4 Department of
Physiotherapy, Auckland University of Technology, Auckland, New Zealand

* [email protected]

Abstract

Workplace bullying are prevalent among the nursing workforce. Consequences of work-

place bullying include psychological stress and workplace accidents and injuries. Psycho-

logical hardiness is proposed as a buffer for workplace bullying and psychological stress on

workplace accidents and injuries. This study adopted the Affective Events Theory and Con-

servation of Resources Theory to develop and test a moderated mediated model in two field

studies. Study 1 (N = 286, Australian nurses) found support for the direct negative effect of

workplace bullying on workplace accidents and injuries with psychological stress acting as

the mediator. The mediation findings from Study 1 were replicated in Study 2 (N = 201, New

Zealand nurses). In addition, Study 2 supplemented Study 1 by providing empirical support

for using psychological hardiness as the buffer for the association between psychological

stress and workplace accidents and injuries. This study offers theoretical and empirical

insights into the research and practice on psychological hardiness for improving the psycho-

logical well-being of employees who faced workplace mistreatments.

Introduction

Workplace bullying is a typical psychosocial risk factor universally prevalent in most work-
places around the world. The Workplace Bullying Institute’s 2017 survey reported approxi-
mate 40% of the bullied targets reported suffering adverse health effects and this incidence
affected 60.4 million Americans [1]. Fevre and colleagues reported that approximately half of
the participants in the United Kingdom experienced some forms of unreasonable treatment at
work and 40% reported workplace disrespect to be the most common phenomenon [2]. Other
studies showed that health sector employees are one of the most vulnerable population to
expose to psychosocial risk at work [3]. As previously reported, 65% of nursing professionals
in the USA observed lateral violence among co-workers [4]. These statistics highlighted the
severity of workplace bullying on the stress of the nursing workforce.

Despite several definitions of workplace bullying [5], the present study adopts the definition
of workplace bullying by Einarsen and colleagues [6] as “harassing, offending, socially

PLOS ONE

PLOS ONE | https://doi.org/10.1371/journal.pone.0244426 January 8, 2021 1 / 15

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a1111111111
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OPEN ACCESS

Citation: Teo STT, Nguyen D, Trevelyan F, Lamm F,
Boocock M (2021) Workplace bullying,
psychological hardiness, and accidents and injuries
in nursing: A moderated mediation model. PLoS
ONE 16(1): e0244426. https://doi.org/10.1371/
journal.pone.0244426

Editor: Sergio A. Useche, Universitat de Valencia,
SPAIN

Received: May 2, 2020

Accepted: December 9, 2020

Published: January 8, 2021

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https://doi.org/10.1371/journal.pone.0244426

Copyright: © 2021 Teo et al. This is an open access
article distributed under the terms of the Creative
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in
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Data Availability Statement: The full data set
cannot be shared publicly because formal approval
was not granted by the Ethics Committee.
However, all relevant data necessary to replicate

excluding someone or negatively affecting someone’s work tasks.” Workplace bullying is a
major source of psychosocial stressors [7, 8] and it is associated with workplace injury com-
pensation claims [9].

An outcome of psychosocial risk factors is accidents and injuries [10]. Common forms of
workplace accidents and injuries among hospital workers include overexertion, falling slips,
trips, and falls, contact with objects or equipment, violence, and an exposure to harmful sub-
stances [10]. These injuries lead to employees taking sick leaves from work. However, there is
inconclusive of the association of psychological stress with workplace accidents and injuries
[10, 11]. Therefore, more attention is needed to enhance the workplace safety of nurses [12].

Scholars have been urged to investigate into workplace bullying in the context of workplace
safety [12]. A meta-analytical review by Christian et al. showed most studies examine the
impact of safety climate and personality factors [13]. Research showed that psychological har-
diness could be treated as an important ‘resistance’ resource [14] which helps employees effec-
tively cope with stressful situations and/or negative work-related events because of the ability
of psychological resilience [15], as explained by the Conservation of Resources (COR) theory
[16]. However, very little is currently known about the moderating role of psychological hardi-
ness in assisting nurses to cope with workplace bullying and its consequent outcomes although
this factor is a potential moderator of stress [17]. We will take up this challenge by proposing
that psychological stress is a mediator and psychological hardiness is a resource which could
be used to buffer the influences of workplace bullying on workplace accidents and injuries
among nurses (Fig 1).

Theoretical background and hypotheses

Workplace bullying and psychological stress

A “good” work environment is associated with better work outcomes such as lower stress and
injury rates [18]. Workplace bullying is an example of “unsafe” psychosocial work environ-
ment [19]. Studies showed that bullying leads to burnout [20], which adversely affects the
physical and mental health of nurses [35]. These symptoms are prevalent in nursing, irrespec-
tive of gender, age, race, education levels, or work history [21]. In Australia and New Zealand,
nurses also experienced workplace bullying and work harassment [22].

The integration of the affective events theory (AET) [23] and the COR theory [16] creates a
potentially useful framework to explain the negative effects of workplace bullying on nurses.
Drawing from the AET, we argue that when employees experience workplace bullying that is a
negatively affective event, they would react emotionally to it which would affect their subse-
quent well-being [5]. Consistent with the COR perspective, an exposure to workplace bullying
could result in the depletion of personal and job resources leading to poor psychological health
state [24]. There has been empirical support for the negative association between workplace
bullying and psychological stress, as shown in a sample of 233 hospital and 208 aged care
nurses from Australia [25]. When nurses are exposed to workplace bullying, they experienced
more burnout as they could not recover psychologically [26].

H1: Workplace bullying has a positive association with psychological stress.

The resulting psychological stress due to workplace bullying could lead to workplace safety
outcomes among nurses. The Institute for Safe Medication Practices reported that 7% of 1,565
nurses were involved in medication errors as a result of experiencing intimidation at work
[27]. Instead of asking for help in an environment where bullying is present, nurses muddle
through an unclear procedure, use an unfamiliar piece of medical equipment without seeking
help, lift heavy, or debilitated patients alone [28]. These actions not only are prone to cause

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the study’s results are within the paper and its
Supporting Information files.

Funding: Funding was provided by the Auckland
University of Technology as a research grant
awarded to Teo, Lamm and Boocock. Authors
Trevelyan, Lamm, and Boocock are full time
employees of the funder (Auckland University of
Technology).The funders had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.

Competing interests: The authors have declared
that no competing interests exist.

accidents that compromise patient care and safety, but also can cause injuries to themselves and
jeopardize their safety. Salminen et al. provided empirical support between injuries and interper-
sonal relationship problems as examples of workplace bullying behaviors [11]. Other studies
found that workplace bullying among nurses could result in stress-related symptoms such as acci-
dents and errors [29] and negatively affects the quality and safety of patient care [30]. A recent
systematic review supported the positive association between workplace bullying and injuries as
“unsupportive social relationships” are related to higher levels of employee injury [31].

H2: Workplace bullying has a positive association with workplace accidents and injuries.

Psychological stress and workplace accidents and injuries

Workplace bullying has been found to lead to poor mental well-being [5] and emotional
exhaustion [9]. AET perspective could be used to explain these relationships [5]. These health
problems could cause a loss of concentration and vigilance at work that increases the chance of
making mistakes and the likelihood of work accident and injury events, both physical (e.g.,
needle injuries) and psychological (e.g., violence) [32]. Bullying was perceived to be associated
with occupational injuries [33]. There is also evidence supporting the association between bul-
lying and suicidal ideation or attempted suicide, which is the ultimate injury due to extreme
psychological stress [34].

Fig 1. Proposed moderated mediation model. Note: Control variables: tenure, gender, supervisory role, age and marker variable (social
desirability), Study 1: Hypotheses 1 to 4, Study 2: Full model (Hypotheses 1 to 4 and moderation hypotheses).

https://doi.org/10.1371/journal.pone.0244426.g001

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H3: Psychological stress has a positive association with workplace accidents and injuries.

Workplace bullying could also result in sleep disorders and fatigue as well as moderate and
high levels of psychological stress that increase the risk of work-related accidents and injuries
[35]. To reduce the physiological stress of being bullied, some employees even developed
excessive alcohol consumption that is a risk factor for accidents and injuries at work to cope
with bullying [36]. Others [37] argued that the association between bullying-related psycholog-
ical stress and work-related accidents and injuries was caused by nurses’ cognitive failures in
performing their daily tasks.

H4: Psychological stress mediates the positive association of workplace bullying on accidents and
injuries at work.

Moderation effects of psychological hardiness

Psychological hardiness has received an increasing interest in high-stress, first respondent
occupations such as military [38] and nursing [39]. Hardiness is “a constellation of personality
characteristics that function as a resistance resource in the encounter with stressful life events”
[40]. A hardy personality comprises of commitment, control, and challenge attitudes that pro-
vide a pathway to resilience that facilitates the possibility to turn “stressful circumstances”
from adversity into advantage and growth opportunities [14, 41]. Hardy individuals experi-
ence stressful work situations in ways that they appraise the potentially stressful situations as
less threatening, thus, minimizing their experience of stress [38]. Indeed, research has long rec-
ognized that psychological hardiness acts as a protective or buffer factor in coping with work-
related stress [42] and a resilience factor against the development of PTSD syndromes [43]. A
recent study noted the importance of developing the resilience of nurses in New Zealand in
creating a practice environment which reduces workplace bullying [44]. Consistent with these
arguments, we argue that psychological hardiness is important in helping nurses cope with
workplace bullying.

The COR theory [16] could be used to hypothesize a moderation model where bullying
leads to resource depletion among nurses who have resources and where this depletion subse-
quently reduces health and well-being. The COR theory posits that “people strive to retain,
protect and build resources and that what is threatening to them is the potential or actual loss
of these valued resources” [16]. Under this theory, workplace bullying is considered as a stress-
ful working condition which brings about employees’ experience with a substantial loss or a
depletion of both personal and job-related resources [45]. Therefore, they would utilize other
available resources to protect and/or to prevent further resource loss.

Consistent with the COR literature [16], we argue that psychological hardiness is one
such protectively personal resource to buffer the negative effects of bullying on psychologi-
cal stress. Indeed, psychological hardiness can aid stress resistance through its attributes of
optimism and resiliency, which explains the tendency that hardy people appraise stressful
events less threatening, thus diminishing stress symptoms [41]. As the three sub-dimen-
sions of psychological hardiness were negatively associated with psychological stress [42],
previous studies provided evidence for the contribution of psychological hardiness in buff-
ering the negative impacts of stress on the well-being of employees. For instance, hardiness
was found to moderate the effect of threats on psychological stress in a sample of 820
undergraduate students in the USA [46]. Workplace bullying can be a source of “threat” to
employee work outcomes and well-being [47]. As a result, hardy employees can utilize
their high hardiness to dampen the impacts of workplace bullying on their mental health
[40, 48].

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H5a: Psychological hardiness moderates the relationship between workplace bullying and psycho-
logical stress such that higher psychological hardiness reduces the positive effect of workplace
bullying on psychological bullying.

There is support for psychological hardiness to dampen the influence of psychological stress
on accidents and injuries among hardy workers. For instance, hardiness was found to buffer
the effect of stress on illness [14]. Nurses with high hardiness in a high-stress circumstance
tend to use 57% fewer sick hours than those reported low hardiness and low stress [39]. Hardy
employees are likely to cope effectively with stressful work events, which lead to work perfor-
mance and well-being. This will lead to a reduction in the likelihood of work-related accidents
and injuries.

However, there were inconclusive findings on the relationship between psychological har-
diness, stress, and health. There was empirical support for the moderation effect of hardiness
on stress and symptoms of illness [49]. On the other hand, others did not find any empirical
support for psychological hardiness as a moderator [11]. Therefore, more research is needed
to further understand the buffering effect of hardiness on workplace accidents and injuries
caused by work-related stress.

H5b: Psychological hardiness moderates the relationship between psychological stress and work-
place accidents and injuries such that higher psychological hardiness reduces the positive effect
of psychological stress on workplace accidents and injuries.

Materials and methods

Written consent was granted from the ethics committee of Auckland University of Technology
prior to data collection (AUT Ethics Committee; Written approval number: AUTEC Lamm
15/373). We conducted two studies to test the hypothesized model. We utilized IBM AMOS
version 25 to conduct confirmatory factor analysis (CFA) for each of the previously validated
scales used in this study. Cut-offs for the goodness of fit indices for the scale validity and the
estimation of measurement model were consistent with the recommendation in the literature
for structural equations modelling [50]. Written ethics approval was obtained from the univer-
sity’s ethics committee prior to data collection (AUT Ethics Committee; Written approval
number: AUTEC Lamm 15/373).

Overview of studies

We tested the hypotheses in two field studies. In Study 1, we tested the mediating effect of psy-
chological stress on the relationship of workplace bullying with workplace accidents and inju-
ries using a sample of Australian nurses. A second study was designed to replicate and validate
the findings from Study 1. In addition, we test the buffering effects of psychological hardiness
on workplace bullying ! psychological stress ! accidents and injuries (H5) with a sample of
nurses from New Zealand.

Study 1: Australian nurses

A market research company from Australia provided assistance with data collection. Austra-
lian nurses who were older than 18 years and resident of Australia were invited to complete
the online survey in 2015 (approximate response rate 26%). We received completed surveys
from 287 respondents. Most of the respondents (69.7%) were female and approximately half of
the respondents were employed in public sector hospitals. Of the respondents, 85.7% were
younger than 50 years old. Nearly two-thirds of the respondents did not hold a supervisory

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position. Additionally, the majority (75.3%) were full-time nurses. Finally, most of the respon-
dents had less than 5 years of organizational tenure.

Measures

Workplace bullying. Workplace bullying was measured by using the nine-item NAQ-R
short form [51]. Respondents were asked to indicate how often they experienced the negative
acts at work, ranging from ‘1’ never to ‘5’ daily. A sample item included ‘social exclusion from
co-workers or work-group activities’.

Psychological stress. Psychological stress was measured using the K-10 Kessler Psycho-
logical Stress scale [52], ranging from ‘1’ none of the time to ‘5’ all of the time. A sample item
was ‘did you feel so nervous that nothing could calm you down?’

Workplace accidents and injuries. We used five types of workplace accidents injuries
typically found in organizations [10, 11, 53, 54]. The respondents were asked to indicate their
agreement on a 7-point Likert scale, ranging from ‘very rarely/never’ to ‘very often (several
times an hour). Sample items included ‘Work-related accidents and or injuries from “trips,
slips and falls”‘.

Control variables. In this study, we controlled for: age [34], gender [14, 33], supervisory
role [55], and organizational tenure [21]. These variables have been shown to have a confound-
ing effect on the latent constructs.

Discriminant analysis

To minimize common method variance (CMV), we utilized procedural remedies and post hoc
statistical checks (such as Harman’s single-factor model test and “social desirability” scale as
the marker variable) to ensure CMV is of no major concern [56]. Harman’s single-factor
resulted in five factors where the largest factor accounted for 39.2% variance. The Marlowe-
Crowne Social Desirability scale [57] was incorporated into the model as marker variable [58].
The test showed that the difference of the correlations between exogenous and endogenous
variables before and after including the marker variable was 0.09, below the cut-off value of 0.2
[58]. These findings indicated that CMV was not a major issue in this study.

We also conducted Chi-square nested model tests to compare the changes in λ2 of the
hypothesized three-factor model with that of alternative models for discriminant validity
(Table 1). Results showed that the preferred model has a satisfactory fit with the data (λ2/
df = 1.923, df = 224, CFI = 0.975, TLI = 0.969, RMSEA = 0.057, SRMR = 0.037).

Results: Study 1

Descriptive statistics and intercorrelations are reported in Table 2. Male nurses experienced
higher level of workplace bullying (β = 0.18, p<0.01) and more workplace accidents and

Table 1. Results for Chi-square difference test in Study 1.

Model χ2 df CFI TLI RMSEA SRMR Δχ2 from 3-factor model

3-factor model (WB, PS, A&I) 430.72 224 0.975 0.969 0.057 0.0371

2-factor model (WB, PS+A&I) 1137.709 226 0.889 0.864 0.119 0.1108 706.989 (df = 2), ⇤⇤⇤

1-factor model (WB+PS+A&I) 1993.598 227 0.785 0.738 0.165 0.1290 885.889 (df = 1), ⇤⇤⇤

Note: WB = workplace bullying; PS = psychological stress; A&I = accidents and injuries
⇤⇤⇤p<0.001.

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injuries (β = 0.22, p<0.001). Older respondents had more tenure in their hospital (β = 0.46,
p<0.01). These control variables were incorporated into model testing.

Path analysis showed that workplace bullying had a positive association with psychological
stress (β = 0.72, p<0.001) and workplace accidents and injuries (β = 0.52, p<0.001). Psycho-
logical stress had a positive association with workplace accidents and injuries (β = 0.29,
p<0.001). Psychological stress was a partial mediator of the effect of workplace bullying on
accidents and injuries (effect = 0.351, se = 0.089, 95%CI = 0.219, 0.510).

In summary, Study 1 provided empirical support for Hypotheses 1 to 4. Consistent with the
literature and the AET perspective [23], nurses reacted negatively to having experienced nega-
tive workplace events such as bullying exposure results in psychological stress [5]. We contrib-
uted to the literature by empirically showed the direct relationship between psychological
stress and workplace accidents and injuries.

Study 2: New Zealand nurses

Study 2 was designed to test the moderated mediation model. Data were collected from a
cross-sectional sample of 201 New Zealand nurses in 2016. Most of the respondents were
female and the majority were from the North Island (such as Auckland, Wellington, and Ham-
ilton) and Christchurch in the South Island. Nearly half of the respondents were between 26–
40, followed by 51–60 years old (15.4%). A large majority were full-time employees.

Measures

We used the same three variables from Study 1 with the same rating scales. Similar to Study 1,
we controlled for confounding effects with the same set of demographic variables. Also, we
introduced psychological hardiness as a moderator into Study 2 to replicate the findings from
Study 1 and to test the moderation hypotheses. Psychological hardiness was measured using a
six-item scales [15], ranging from ‘1’ strongly disagree to ‘7’ strongly agree. We used a total
score approach by combining the scores from the three sub-dimensions (commitment, con-
trol, and challenge) into a second order, composite hardiness score (sample item includes
‘despite setbacks, I remain committed to accomplishing job tasks’).

Discriminant analysis

Discriminant analysis was undertaken with a series of Chi-square nested model tests (see
Table 3), by comparing the four-factor (hypothesized model) with alternate models. Results

Table 2. Descriptive statistics and inter-correlations in Study 1.

Mean SD 1 2 3 4 5 6 7

1. Age 1.70 0.46 1.00

2. Gender 3.99 1.30 0.05 1.00

3. Supervisory role 1.61 0.49 0.10 -0.06 1.00

4. Tenure 3.02 1.22 0.01 0.46⇤⇤ -0.07 1.00

5. WB 1.93 0.94 -0.18⇤⇤ -0.30⇤⇤⇤ -0.10 -0.21⇤⇤⇤ 1.00

6. PS 2.30 0.98 -0.07 -0.34⇤⇤⇤ 0.00 -0.33⇤⇤⇤ 0.71⇤⇤⇤ 1.00

7. A&I 3.32 1.61 -0.22⇤⇤⇤ -0.27⇤⇤⇤ -0.11 -0.28⇤⇤⇤ 0.57⇤⇤⇤ 0.56⇤⇤⇤ 1.00

Note: N = 287 Australian nurses, Gender (‘1’ male, ‘2’ female), Supervisory role (‘1’ yes, ‘0’ no), SD: standard deviation
⇤⇤p<0.01
⇤⇤⇤p<0.001.

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showed that the hypothesized four-factor model had the best fit (λ2/df = 1.728, CFI = 0.94,
TLI = 0.93, RMSEA = 0.06, SRMR = 0.07). We conducted the incorporation of a marker variable
(social desirability) to check for CMV. The test showed that the difference of the correlations
between endogenous and exogenous variables before and after including the marker variable was
0.13, below the cut-off value of 0.2 [58], indicating that CMV was not a major issue.

Results

Descriptive statistics and intercorrelation coefficients are reported in Table 4. Female respon-
dents were older, held supervisory positions, and had more tenure. Supervisors had more
experienced in the organization. As a result of the bivariate analysis, these control variables
were also incorporate into the path analyses.

Results of the path modelling showed tenure to have a negative association with psychologi-
cal stress (β = -0.13, p<0.05) and workplace accidents and injuries (β = -0.21, p<0.001),
respectively. As shown in Fig 2, there was support for Hypotheses 1–4 which demonstrated a
mediational model (b = 0.15, SE = 0.05, 95%CIs = 0.07, 0.24). Using the Johnson–Neymann
(J–N) technique, we found psychological hardiness was found to buffer the effect of workplace
bullying on workplace accidents and injuries (b = -0.20, SE = 0.04, 95%CIs = -0.25, -0.49,
p<0.001). Mediation analysis was performed using the estimand plug-in [59] in IBM AMOS
version 25. Psychological hardiness was found to be a moderator of the indirect effect of work-
place bullying on workplace accidents and injuries as mediated by psychological stress
(b = 0.12, SE = 0.05, 95%CIs = 0.04, 0.22, p<0.05). This finding provides support for Hypothe-
sis 5b. As shown by the moderation plot (Fig 3), in the presence of high psychological

Table 3. Results for Chi-squared comparison test in Study 2.

Model χ2 df CFI TLI RMSEA SRMR Δχ2 from 4-factor model

4-factor model (WB, PS, PH, A&I) 800.074 463 0.938 0.929 0.060 0.063

3-factor model (WB, PS, PH+A&I) 1180.462 466 0.868 0.851 0.088 0.107 380.388 (df = 3)⇤⇤⇤

2-factor model (WB, PS+PH+A&I) 1566.952 468 0.798 0.772 0.108 0.124 386.49 (df = 2)⇤⇤⇤

1-factor model (WB+PS+PH+A&I) 1808.407 469 0.753 0.722 0.119 0.138 241.455 (df = 1)⇤⇤⇤

Note: WB = workplace bullying; PS = psychological stress; PH = psychological hardiness; A&I = accidents and injuries
⇤⇤⇤p<0.001.

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Table 4. Descriptive statistics and inter-correlations in Study 2.

Mean SD 1 2 3 4 5 6 7 8

1. Age 3.15 1.55 1.00

2. Gender 1.76 0.43 0.23⇤⇤ 1.00

3. SR 0.30 0.46 0.30⇤⇤⇤ 0.07 1.00

4. Tenure 2.99 1.31 0.57⇤⇤⇤ 0.23⇤⇤ 0.28⇤⇤⇤ 1.00

5. WB 1.73 0.85 -0.22⇤⇤ -0.22⇤⇤ 0.03 -0.22⇤⇤ 1.00

6. PS 1.06 0.39 -0.30⇤⇤⇤ -0.13 -0.08 -0.33⇤⇤⇤ 0.60⇤⇤⇤ 1.00

7. PH 4.42 0.64 0.24⇤⇤⇤ 0.30⇤⇤⇤ 0.14 0.23⇤⇤ -0.30⇤⇤⇤ -0.31⇤⇤⇤ 1.00

8. A&I 1.49 0.90 -0.32⇤⇤⇤ -0.25⇤⇤⇤ -0.02 -0.30⇤⇤⇤ 0.66⇤⇤⇤ 0.59⇤⇤⇤ -0.38⇤⇤⇤ 1.00

Note: N = 201 New Zealand nurses, Gender (‘1’ male, ‘2’ female), SR: Supervisory role (‘1’ yes, ‘0’ no), SD: Standard Deviation
⇤⇤p<0.01
⇤⇤⇤p<0.001.

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Fig 2. Results of hypotheses testing in Study 2. Note: N = 201, ⇤p<0.05, ⇤⇤⇤p<0.001.

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Fig 3. Moderation of psychological hardiness on stress and accidents and injuries.

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hardiness, this would reduce the negative impact of psychological stress on workplace acci-
dents and injuries. In summary, the model supported a moderated mediation model where
psychological stress was a partial mediator of the effect of workplace bullying on workplace
accidents and injuries.

Discussion

Theoretical implications

This study aimed to test a moderated mediation model using two samples of nurses where we
hypothesized that the negative impact of workplace bullying on accidents and injuries at work
would be mediated by psychological stress. The indirect effect of workplace bullying on work-
place accidents and injuries through psychological stress were then moderated by the degree
of psychological hardiness. Our findings contribute new insights into the limited knowledge of
the workplace safety of nurses in the context of workplace bullying.

The AET [23] posits that employees would react emotionally to the negative affective events
like workplace bullying that would affect their subsequent behaviors, attitudes, and well-being
in responding to the respective event [5]. We supported previous studies [45] by providing
strong support for a partial mediation model, where psychological stress as the mediator, con-
tributed to workplace accidents and injuries when nurses encounter workplace bullying. Stated
differently, our study provided support for the evidence that workplace bullying exposure
could result in accidents and injuries [34] via psychological stress [5].

As the COR theory [16] posits, the prevalence of workplace bullying is perceived to be a
stressful working condition that could develop perceptions of substantial resource threats or
loss or the experience of resource depletion [45]. As previously argued, psychological hardiness
is a type of protective personal resources that individuals can utilize to preserve other resources
or prevent further resource loss in coping with stress [38, 43]. While we did not find the role of
psychological hardiness in buffering the negative consequences of workplace bullying on psy-
chological stress (H5a), we did find psychological hardiness to buffer the effect of psychological
stress on workplace accidents and injuries (H5b). This was due to the partial mediation effect
of psychological stress caused by workplace bullying (H4). The significant finding in our study
supported the existing literature using psychological hardiness as the moderator for psycholog-
ical stress [17, 46]. Indeed, individuals with high positive affectivity are less likely to perceive
workplace bullying and are of low risk to become targets of bullying [60]. On the other hand,
individuals high in negative affectivity are more likely to feel bullied or mistreated because
they are more sensitive and more reactive to negative events [61]. Therefore, we concluded
that nurses who are high in hardiness are less likely to experience bullying than those who are
low in hardiness.

Practical and managerial implications

Our findings have several practical implications. To minimize the prevalence of workplace bul-
lying, several strategies could be used to attract and select managers who do not demonstrate
laissez-faire leadership behaviors [62] or Machiavellian behaviors [63]. Similarly, selection
strategies could be adopted to ensure newcomers do not fit the profile of bullies [30]. Senior
management must take an ethical stand in promoting “ethical work environments devoid of
interpersonal mistreatment” [64], which is consistent with the work environment hypothesis
in explaining workplace bullying [7].

Various strategies could be developed to build on the three dimensions of psychological
hardiness (such as commitment, control, and challenge). For example, HR managers could
consider the implementation of educational programs to improve the resilience [8] and or

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psychological hardiness of nurses [65]. Henderson used a hardiness training program as an
intervention tool to educate nurses on developing strategies to strengthen the three dimen-
sions of psychological hardiness (i.e. commitment, control, and challenge) and supplemented
this with specific strategies for nurses to practice their assertiveness, active involvement
(instead of avoidance) in stressful events and view these challenges as growth opportunity [65].
Through education intervention programs, nurses would be given the psychological resources
to buffer the negative consequences of negative workplace behaviors [10]. This is consistent
with the COR perspective [16].

The above intervention examples were included in a recently developed typology [66].
Caponecchia et al. identified 11 core intervention types (investigation, codes of conduct, pol-
icy; EAP and counselling, bullying awareness training, coaching, system-wide intervention,
skills training and development, values statements, local resolution, and organizational rede-
sign). HR professionals could consider implementing these interventions to enhance the well-
being of nurses. More research is also needed to examine the effectiveness of primary versus
secondary versus tertiary interventions [67] as these could have a different impact on training
nurses to effectively deal with their exposure to workplace bullying.

Limitations and future implications

The current study found that CMV is not a major concern through some statistical checks for
common method variance as well as the significant impacts of moderated mediation [56]. We
still acknowledged that the findings could potentially be affected by a single source bias. There-
fore, future studies could rely on objective organizational data on accidents and injuries
instead of relying on self-reported data from the participants.

Consistent with the AET, future research could adopt self-regulation theory to collect
multi-source data to evaluate how nurses regulate their emotions resulting from the exposure
to workplace bullying [68]. Another possibility is to design studies to collect longitudinal data
to test for the effect of workplace bullying on individual and work safety outcomes [24]. Future
study could potentially collect data such as the ward/unit as these could control for unit-level
variances on work environment, which could affect the prevalence of exposure to workplace
bullying [69, 70].

Conclusion

In conclusion, psychological hardiness was found to be a moderator of the partial mediation
effect of psychological stress due to workplace bullying on workplace accidents and injuries.
This study contributed to the knowledge of psychological hardiness and was consistent with
literature [15]. We concluded that when nurses possessed a high level of psychological hardi-
ness, they were better at being resilient and possess the ability to cope effectively when they
experience negative treatments at work.

Supporting information

S1 File.
(DOC)

Author Contributions

Conceptualization: Stephen T. T. Teo, Diep Nguyen, Fiona Trevelyan.

Data curation: Stephen T. T. Teo.

PLOS ONE Workplace bullying and hardiness

PLOS ONE | https://doi.org/10.1371/journal.pone.0244426 January 8, 2021 11 / 15

Formal analysis: Stephen T. T. Teo, Diep Nguyen.

Funding acquisition: Stephen T. T. Teo, Felicity Lamm, Mark Boocock.

Investigation: Stephen T. T. Teo.

Methodology: Stephen T. T. Teo, Diep Nguyen.

Project administration: Stephen T. T. Teo.

Resources: Fiona Trevelyan, Felicity Lamm.

Software: Diep Nguyen.

Writing – original draft: Stephen T. T. Teo, Diep Nguyen.

Writing – review & editing: Fiona Trevelyan, Felicity Lamm, Mark Boocock.

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Discussion 1 diversity

 

Discuss the following:

  • The Purnell Model for Cultural Competence and its relevance for advanced practice nurse.
  • The importance of effective communication that promotes cultural competence.

Submission Instructions:

  • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 3 academic sources.

Family assessment

 This learning activity aims for a full understanding and unbiased view of the family—not just its problems, but also its strengths, values, and goals. Understanding family structure and style is essential to caring for a family in the community setting. Conducting a family interview and needs assessment gathers information to identify strengths, as well as potential barriers to health. This information ultimately helps develop family-centered strategies for support and guidance. 

See the Interview Questionnaire in the attached document below.

Family assessment assignment- community.docx Download Family assessment assignment- community.docx

Upon completion of the interview, write a 750-1,000-word post.

Analyze your assessment findings and the family’s answers to your questions. Family health assessment is a two-part assignment. The information you gather in the first part of the assignment will be utilized for the second part of the assignment.  

  1. Select a family, other than your own, and seek permission from the family to conduct an interview. Utilize the interview questions complied in your interview questionnaire to conduct a family-focused functional assessment.
  2. Document the responses as you conduct the interview. Do not put the family’s name, but utilize initials, the gender of each family member, and their age.

Your work must include the following:

  • Describe the family structure. Include individuals and any relevant attributes defining the family composition, race/ethnicity, social class, spirituality, and environment.
  • Summarize the overall health behaviors of the family. Describe the current health of the family.
  • Based on your findings, describe at least two of the functional health pattern strengths noted in the findings.
  • Discuss three areas in which health problems or barriers to health were identified?
  • Your assignment must include an eco-map and a genogram – as shown in the required textbook. 

Submission Instructions:

  • The work is to be clear and concise and students will lose points for improper grammar, punctuation and misspelling.
  • The work is to be 750-1000 words in length, excluding the title, abstract and references page.
  • Incorporate a minimum of 3 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style (the library has a copy of the APA Manual).
  • Your work should be formatted per APA and references should be current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions)

Understanding family structure and style is essential to caring for a family in the community setting. Conducting a family interview and needs assessment gathers information to identify strengths, as well as potential barriers to health. This information ultimately helps develop family-centered strategies for support and guidance.

This family health assessment is a two-part assignment. The information you gather in the first part of the assignment will be utilized for the second part of the assignment.  

Select a family, 
other than your own
, and seek permission from the family to conduct an interview. Utilize the interview questions complied in your interview questionnaire to conduct a family-focused functional assessment. Document the responses as you conduct the interview. Do not put the family’s name, but utilize initials, the gender of each family member, and their age.


The Interview Questionnaire

Develop an interview questionnaire to be used in a family-focused functional assessment. The questionnaire must include open-ended, family-focused questions to assess functional health patterns for each of the following:

1. Collect information about the family’s environment. Is it a single-family dwelling? Are there hazards in the environment, accident hazards, do they have indoor plumbing and cooking facilities? What type of heating or cooling system is being used in the home?

2. Does anyone in the family smoke, use chewing tobacco, consume alcohol, or illegal drug use? 

3. Values/Health Perception – how does the family assess their health status? What do they feel that they need to work on or trouble areas?

4. Who is the head of the household? Who has the final say in family decisions?

5. Does the family operate with specific assigned roles, or are the roles less defined? Who cooks dinner? Who does chores? Who helps the children with homework, bathes, and feeds them? 

6. How is the family performing in their roles? Are there work or school-related strain? Are the children performing well in school? 

7. Role Relationship- are the interactions within the family healthy or strained?

8. What are the family’s health-related behaviors? (Nutrition, Sleep, Activity/Exercise)

9. How does the family earn their income? Do the parents both work? 

10. Are there cultural issues that are unique to the family? Do they use home remedies or other complementary health methods? 


Upon completion of the interview, write a 750-1,000-word paper
.

Analyze your assessment findings and the family’s answers to your questions. 


Include the following in your paper:

1. Describe the family structure. Include individuals and any relevant attributes defining the family composition, race/ethnicity, social class, spirituality, and environment.

2. Summarize the overall health behaviors of the family. Describe the current health of the family.

3. Based on your findings, describe at least two of the functional health pattern strengths noted in the findings. Discuss three areas in which health problems or barriers to health were identified?

4. Your assignment must include an eco-map and a genogram- as shown in the required textbook. 


The Interview Questionnaire

Develop an interview questionnaire to be used in a family-focused functional assessment. The questionnaire must include open-ended, family-focused questions to assess functional health patterns for each of the following:

1. Collect information about the family’s environment. Is it a single-family dwelling? My name is EP, I’m 48 years old. My Wife’s name is JY, she is 44 years old. We have 3 children; the twins are 8 and SV. She is 10 years old. We have a four-bedroom home which is occupied by our family only.

2. Are there hazards in the environment, accident hazards, do they have indoor plumbing and cooking facilities? What type of heating or cooling system is being used in the home? We have been living here for a very long time and since we bought this house and had our children, we have tried our best to make this a safe environment for them. We try not to keep things around that are potentially hazardous to us. My wife and I make sure not to keep sharp objects around, we always try to keep the house clean. Yes, we have water running through the entire house and we have a kitchen that is well equipped with a stove, microwave, and a toaster as well as a refrigerator. In our home we have an air conditioner which provide us with central air and heating.

3. Does anyone in the family smoke, use chewing tobacco, consume alcohol, or illegal drug use? No smoking, chewing tobacco or illegal drug use. From time to time my wife and I will have a drink, but that is mostly when we go out to spend some alone time together.

3. Values/Health Perception – how does the family assess their health status? What do they feel that they need to work on or trouble areas? My wife and children are healthy, but I do have an issue with diabetes. We could work on spending more quality time together. One of the biggest problems we are facing right now is financial problems. We are still doing pretty good with keeping up with the bills and putting food on the table. We are a great team.

4. Who is the head of the household? Who has the final say in family decisions? I, the husband, is the head of the household, but I do not make big decisions that will have a major impact on the entire family without involving my wife.

5. Does the family operate with specific assigned roles, or are the roles less defined? Who cooks dinner? Who does chores? Who helps the children with homework, bathes, and feeds them? 

6. How is the family performing in their roles? Are there work or school-related strain? Are the children performing well in school? In our family, my wife plays the role of emotional supporter, I am the disciplinarian, and my daughter is the big sister that watches her little brothers when were not available. Both my wife and I play the roles of provider, but right now I am playing the major role where that is concerned as my wife is self-employed and it is very slow at her work right now. My wife does not like cooking so I do most of the cooking even though there are rear occasions when she will cook. The kids are doing amazing in school. They don’t give us trouble in that sense.

7. Role Relationship- are the interactions within the family healthy or strained?

It is very healthy, we blessed with each other. We both do the best to make our life and our kids life easier.

8. What are the family’s health-related behaviors? (Nutrition, Sleep, Activity/Exercise)

My wife and kids have a pretty active and healthy life. My wife has a gym set up in the garage. She also runs every morning before she gets the kids ready for school. The kids play sport in their school. The only lazy one is me. After work, I just want to seat in front of the TV to watch some games and eat. No wonder why I’m the only sick one.

9. How does the family earn their income? Do the parents both work? Yes , we both work.

10. Are there cultural issues that are unique to the family? Do they use home remedies or other complementary health methods? No, we do not have any cultural issues. We are big on holidays. We celebrate each holiday together as family. We do not have experience with home remedies. If any of us are sick, we just go to the near clinic.

Alternative preventative measures

Please see Attachment for Instructions

Alternative Preventative Measures

Discussion Topic

 Top of FormBottom of Form

Discussion Prompt

Conduct an internet search focusing on alternative methods of preventative care, i.e spiritual care, pet care, music therapy, etc. Compile a minimum of three (3) internet resources that address preventative health care and post to the DB.  Discuss the benefits and limitations to each resource, how these resources can be incorporated into patient care, and what population would benefit most from these.

Expectations

Initial Post:

APA format with intext citations

Word count minimum of 250, not including references.

References: 2 high-level scholarly references within the last 5 years in APA format.

Plagiarism free.

Turnitin receipt.


Chapter 23 – assignment

Chapter 23 – Assignment

Scenario – As a staff member who serves on the Quality Improvement Planning Committee, you are at a meeting to discuss the best way to share information about recent CQI data so that staff in the hospital can appreciate the value of the data. You need to identify pros and cons of methods the committee might use to assess and describe data for planning purposes.

The committee is mostly new, some members have limited experience. You and two other members have the most experience, so you three volunteer to help the others get up to speed as quickly as possible so that decisions can be made about steps to take with the data, and you can get to decisions about strategies. You make clear to the other committee members that 1) this is a team effort and 2) the team must engage hospital staff at all levels. “You comment, “We have tried to keep this to ourselves, thinking only we knew the best approaches, and we failed.” Staff do not feel engaged in CQI and complain about the extra work for which they see no value.

Instructions:

  1. Read the scenario above and then, answer the following questions:
    1. What are some of the barriers that could be influencing limited staff engagements? 
    2. What strategies might be used to overcome these barriers?
    3. What are the pros and cons of the methods used to assess and describe the need for change?
    4. What are the common reasons staff members resist change?
    5. Are standards of practice valuable sources of data for such a committee? Why or why not? Which ones might be of particular use?
  2. Your assignment should be: 
    • One (1) page
    • Typed according to APA style for margins, formatting and spacing standards
    • Typed into a Microsoft Word document, save the file, and then upload the file

Student response 2

Discussion: Leadership Profile

The StrengthsFinder assessment is a personal development tool developed by Gallup Education, which provides an individual with their top 5 strengths. Focusing on your strengths on a daily basis has been shown to have profound positive effects on an individual’s personal and professional well-being (Comer et al., 2019). My strengths, according to the StrengthsFinder assessment, are focus, consistency, strategy, achiever, and responsibility. Being focused means that I regularly set goals that act as my compass, regularly evaluate actions to determine whether they help move in the right direction, and tends to be impatient with tangents, obstacles, and delays. Being consistent means that I value balance, I am keenly aware of the need to treat people the same, and believe that people function in an environment where rules are clear. Being strategic means that I am able to sort through the clutter and find the best route, being an achiever means that I have a constant need for achievement, and responsibility means that I take ownership of anything I am committed to and become emotionally bound to follow it through to completion.

The two core values that I would like to strengthen, based on the results of the StrengthsFinder assessment, are honesty and loyalty. The results indicate that I am a dependable person because of my consistency, taking ownership of others, desire to achieve, and establishing the right direction. Because others rely on me for all these, it means that I need to be trusted hence; the value of honesty. Honesty is important in gaining stronger support from employees and allows the right solutions to be applied (Karthikeyan, 2018). I can effectively lead others if I am loyal to my job and role as a leader. Loyalty sets leadership apart from management and enables leaders to continuously remind their team of organizational goals and vision (Steinmann et al., 2018).

The strengths that I intend to strengthen further, based on the StrengthsFinder assessment results, are accountability and persistence. The health care setting represents an important setting where results play an important role. A focus on higher and positive results is the goal of healthcare providers. Working on my strengths as an accountable and persistent leader can help me to remain accountable in all my tasks and initiatives, and be successful in promoting positive outcomes, respectively. In addition to this, leader effectiveness ensures that organizational objectives are carried out in accordance with organizational vision and mission, implying the need to remain accountable and an achiever.

The characteristics that I would like to strengthen based on the StrengthsFinder assessment results are effective negotiation skills and self-awareness. The results indicate that I have dependability values, implying that I am likely to undertake positions where I am supposed to lead others in navigating various situations.  Having good negotiation skills helps in creating good relationships and understanding the interests of those that are being led with the aim of finding ways of satisfying those interests. This strategy can help in influencing others towards the achievement of success or common goals. According to the results, I am aware that my subconscious mind continuously absorbs information and creates possible options. Being self-aware will help me to identify my strengths and weaknesses, and ways of addressing them so that I can continually improve on my skills as a leader.

References

Comer, R., Schweiger, T., & Shelton, P. (2019). Impact of students’ strengths, critical thinking skills and disposition on academic success in the first year of a PharmD program. American Journal of Pharmaceutical Education83(1), 6499. https://doi.org/10.5688/ajpe6499

Karthikeyan, C. (2018). A meta-analytical study on leadership integrity: a leadership ethics perspective. Journal Homepage: http://www. ijmra. us7(4). IJMRA-11476.pdf

Steinmann, B., Klug, H., & Maier, G. (2018). The path is the goal: How transformational leaders enhance followers’ job attitudes and proactive behavior. Frontiers in Psychology9. https://doi.org/10.3389/fpsyg.2018.02338

Must be original due 8/11/22 at 10 pm

 

  • Refer to the “Population-Focused Nurse Practitioner Competencies” found in the Week 1 Learning Resources and consider the quality measures or indicators advanced nursing practice nurses must possess in your specialty of interest.
  • Refer to your “Clinical Skills Self-Assessment Form” you submitted in Week 1 and consider your strengths and opportunities for improvement.
  • Refer to your Patient Log in Meditrek and consider the patient activities you have experienced in your practicum experience and reflect on your observations and experiences.

In 450–500 words, address the following:

Learning From Experiences 

  • Revisit the goals and objectives from your Practicum Experience Plan. Explain the degree to which you achieved each during the practicum experience.
  • Reflect on the three most challenging patients you encountered during the practicum experience. What was most challenging about each?  
  • What did you learn from this experience?  
  • What resources were available? 
  • What evidence-based practice did you use for the patients? 
  • What would you do differently?  
  • How are you managing patient flow and volume?  

Communicating and Feedback 

  • Reflect on how you might improve your skills and knowledge and how to communicate those efforts to your Preceptor. 
  • Answer the questions: How am I doing? What is missing?  
  • Reflect on the formal and informal feedback you received from your Preceptor. 


PMHNP PRAC 6645 Clinical Skills


Self-Assessment Form

Desired Clinical Skills for Students to Achieve

Confident (Can complete independently)

Mostly confident (Can complete with supervision)

Beginning (Have performed with supervision or need supervision to feel confident)

New (Have never performed or does not apply)

Comprehensive psychiatric evaluation skills in: 

Recognizing clinical signs and symptoms of psychiatric illness across the lifespan

X

Differentiating between pathophysiological and psychopathological conditions 

X

Performing and interpreting a comprehensive and/or interval history and physical examination (including laboratory and diagnostic studies) 

X

Performing and interpreting a mental status examination 

X

Performing and interpreting a psychosocial assessment and family psychiatric history 

X

Performing and interpreting a functional assessment (activities of daily living, occupational, social, leisure, educational).

X

Diagnostic reasoning skill in:

Developing and prioritizing a differential diagnoses list

X

Formulating diagnoses according to DSM 5 based on assessment data 

X

Differentiating between normal/abnormal age-related physiological and psychological symptoms/changes

X

Pharmacotherapeutic skills in:

Selecting appropriate evidence based clinical practice guidelines for medication plan (e.g., risk/benefit, patient preference, developmental considerations, financial, the process of informed consent, symptom management) 

X

Evaluating patient response and modify plan as necessary 

X

Documenting (e.g., adverse reaction, the patient response, changes to the plan of care)

X

Psychotherapeutic Treatment Planning:

Recognizes concepts of therapeutic modalities across the lifespan

X

Selecting appropriate evidence based clinical practice guidelines for psychotherapeutic plan (e.g., risk/benefit, patient preference, developmental considerations, financial, the process of informed consent, symptom management, modality appropriate for situation) 

X

Applies age appropriate psychotherapeutic counseling techniques with individuals, families, and/or groups

X

Develop an age appropriate individualized plan of care

X

Provide psychoeducation to individuals, family, and/or groups

X

Promote health and disease prevention techniques

X

Self-Assessment skills:

Develop SMART goals for practicum experiences 

X

Evaluating outcomes of practicum goals and modify plan as necessary 

X

Documenting and reflecting on learning experiences

X

Professional skills:

Maintains professional boundaries and therapeutic relationship with clients and staff

X

Collaborate with multi-disciplinary teams to improve clinical practice in mental health settings 

X

Identifies ethical and legal dilemmas with possible resolutions

X

Demonstrates non-judgmental practice approach and empathy

X

Practices within scope of practice

X

Selecting and implementing appropriate screening instrument(s), interpreting results, and making recommendations and referrals:

Demonstrates selecting the correct screening instrument appropriate for the clinical situation 

X

Implements the screening instrument efficiently and effectively with the clients

X

Interprets results for screening instruments accurately

X

Develops an appropriate plan of care based upon screening instruments response

X

Identifies the need to refer to another specialty provider when applicable

X

Accurately documents recommendations for psychiatric consultations when applicable

X

Summary of strengths:

I have made a lot of progress in my career and profession as nurse practitioner. I acknowledged the significance of self-evaluation and ever since I have embodied the practice of regular self-evaluation as an important component of my career growth. Through my career profession I have master good corporate communication with distinct report writing skills that has enabled me to be one of the best nurses in the facilities I have worked. I have also improved my interpersonal skills significantly that has seen me take up advanced responsibilities from my seniors. I have acquired good work ethics and professionalism. As a nurse I have always maintained the need for respect for patient needs and opinions. My immediate supervisor once marveled at how I handled the case of a Jehovah witness patient who had refused blood transfusion since it was against the doctrines of her denomination. I obeyed her position but requested her to attest to that in writing so I may not be held culpable for negligence. My supervisor told me that I employed wisdom at its echelons. I am also good in clinical assessment and pharmacological support to my clients. I always work day and night to improve my relationships with my clients. A condition which yields better outcomes in patient conditions when I handle them

Opportunities for growth:

One of the opportunities in my career as a nurse practitioner is diversity. I have always loved to diversify my knowledge and understanding about different pharmacological practices. In this sense, I have managed to improve my knowledge about differential diagnosis. I have been expanding my knowledge through continuous research about such topics which have significantly honed my understanding. I also need to develop good leadership and management practices. I believe with good administrative skills there are a lot of opportunities for vertical mobility. Effective administration calls for good knowledge and better understanding. I need to develop sound knowledge in the field of healthcare administration. I have also realized that good understanding of effective pharmacotherapy support to patients. I have had some slight challenges with prescriptions and recommendations for effective medication. I feel this will contribute to better medication to the patients under my care.

Goals and Objectives for the Practicum

· Goal: To hone my corporate communication skills within the next 10 weeks of my practicum cycle

· Objective: to improve my report writing skills for timely delivery of reports

· Objective: to facilitate effective communication and prescriptions to patients

· Objective: to enhance my negotiation and interaction with colleagues an patients

· Goal: To expand my pharmacological knowledge through advanced studies and research on diagnostic and pharmacological processes

· Objective: to grasp the concept of differential diagnosis

· Objective: to improve personal experience with patients

· Objective: to reduce chances of error of wrong diagnosis on patients

· Goal: To expand my knowledge about professional ethics of healthcare practitioners including understanding their application in real-life situation

· Objective: to avoid cases of litigation both to the institution and to me as a practitioner

· Objective: to promote good work ethics in the institutions and facilities where I will work

· Objective: to promote good public image of nursing as a profession by demonstrating exemplary behavior

· Goal: To continuously engage in educational learning through research, regular training programs such as work study, short courses, and exchange programs to expand my knowledge and understanding of nursing as a profession.

· Objective: to continually nourish my knowledge and expertise

· Objective: to strategically position myself for vertical mobility in the administrative ranks

· Objective: to improve my skills, knowledge and experience to match the dynamic world of nursing.

Signature: Monica Castelao

Date: June 13, 2022

Course/Section: 6645C

Discussion: the inclusion of nurses in the systems development life

 Discussion: The Inclusion of Nurses in the Systems Development Life Cycle

In the media introduction to this module, it was suggested that you as a nurse have an important role in the Systems Development Life Cycle (SDLC). With a focus on patient care and outcomes, nurses may not always see themselves as contributors to the development of new systems. However, as you may have observed in your own experience, exclusion of nurse contributions when implementing systems can have dire consequences.

In this Discussion, you will consider the role you might play in systems development and the ramifications of not being an active participant in systems development.

Post a description of what you believe to be the consequences of a healthcare organization not involving nurses in each stage of the SDLC when purchasing and implementing a new health information technology system. Provide specific examples of potential issues at each stage of the SDLC and explain how the inclusion of nurses may help address these issues. Then, explain whether you had any input in the selection and planning of new health information technology systems in your nursing practice or healthcare organization and explain potential impacts of being included or not in the decision-making process. Be specific and provide examples.

APA Format 

Min 3 resources 

Negotiation

TOPIC -NEGOTIATION IN LEADERSHIP 

  • Introduction/Description of Topic (fully introduce and describe topic in relevance to leaders/leadership)
  • Background information of Topic (provide in-depth background information)
  • Analysis/Discussion (what does the literature say – dig in the literature (at least *2 references. Provide relevant models or charts to assist discussion) 
  • Application to Organizational Leadership (Provide pertinent application of topic to leadership within an organization  – provide key components and examples, is the culture of the organization integral to this style or competency?)
  • Application to Clinical Leadership (Provide pertinent application of topic to leadership within the clinical nursing site – provide key components and examples, is the culture of the clinical nursing site integral to this style or competency?)
  • Example of a Famous Leader that demonstrates this topic – Choose an example of a Leader (past or present) that exemplifies the chosen leadership competency/style. Choose anyone – historical, political, scientific, nursing, medicine, business, military, etc. Describe why this individual fits a particular leadership competency or style. (Collaborative presentations – each choose 1 leader)

Tables and/or charts, models, etc. are very helpful and are strongly encouraged 

Curriculum

  • I am majoring in DNP Psychiatric Mental Health Nurse Practitioner 
  • Reflect on your career goals. Read the descriptions of each concentration and Key Differences between the DNP and PhD/DNS. Describe how the DNP program in your selected concentration track will change your practice. Discuss how this choice better aligns with your professional goals than a PhD degree.
  • Concentration Description: Perform mental health assessment, diagnosis, and management of mental health problems and psychiatric disorders for individuals and families. Synthesize knowledge and theories from advanced practice nursing and related sciences to complete a clinical practicum in psychiatric-mental health care with patients across the lifespan
  • Identify and describe three opportunities for quality and safety improvements in your area of practice that you would like to pursue in your DNP program. ( DNP Psychiatric Mental Health Nurse Practitioner ).
  • When considering our student body at VCU, we recognize that each of our learners has a unique story. Overcoming adversities and challenges in life provides an individual the opportunity for reflection on personal growth and resilience. Describe a significant academic, personal or professional challenge you faced, the actions you took, and the growth that resulted.
  • VCU School of Nursing is committed to sustaining a tradition of educational excellence by preparing future scholars and leaders in health care. Leadership is marked by an ability to collaborate with others, and as a DNP student you will be required to lead your DNP project team. Describe one example of your leadership experience in which you significantly influenced others, helped resolve disputes, or contributed to team efforts over time.