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Is Change Needed in Nursing?

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Filtering through the piles of stories shared by nurses on social media, it is not difficult to conclude that there is something unsettling about the culture of the nursing profession. Drawn to the concept of caring, many nurses will describe for you a passion for service; caring for the sick, injured, and underserved. When asked, many nurses share their desires to work as healthcare professionals in hopes of comforting those who suffer, administering life-saving services, helping others, and changing lives.

The reality of the culture of nursing is far from the dreams shared by nurses. Nurses experience some of the highest rates of workplace violence and bullying.1  Sadly, most workplace assaults, abuse, bullying, and threats go unreported for fear of retaliation, job loss, intimidation, and even, perceptions that it is just part of the job. The impact of violence on the nurse is detrimental not only to the nurse, but the practice environment. The answer to the question of whether change is needed in nursing is clearly evident...the time for change is now, but where do we begin? How do we create sustainable and meaningful changes? The role of the nurse in relation to an alternative approach to nursing leadership, the practice environment is presented for discussion.

The Nurse as a Professional

The role of the nurse as a medical professional is far from the hand-maiden saying ‘yes doctor’ depicted on television shows as the lowly, stereotypical, subordinate to doctors.2  Nurses are highly educated, experienced, and licensed, independent practitioners held to licensing board rules and regulations as is any physician. Nurses can face law-suites, licensure revocation and restrictions, and prison sentencing for failure to practice according to practice standards. Just as doctors take the Hippocratic Oath, nurses take the Florence Nightingale Pledge or a similar pledge to care for and protect the public; a symbol of professionalism and ethical conduct. Nurses work in a collegial relationship with physicians, and registered nurses work without the supervision of another healthcare provider. The scope of practice for nurses and physicians establish different roles and responsibilities as professionals in the care of people.

The reasonable and prudent standards of nursing care governs the practice of the licensed nurse, and holds a standard of care for the nurse as would a professional with similar expert nursing knowledge and skills. Another word, nurses hold each other accountable according to the standards of practice as established by the profession of nursing, and not other disciplines of medicine such as physicians. While the goals may be similar, the disciplines, philosophies, conceptual models, theories, and evidenced based practice standards of care differ between nurses and physicians.

The bottom line is that nurses are responsible for their individual practices. The professional license issued to the nurse requires that abide by the nurse practice act, and uphold acceptable practice standards accordingly. Nurses are not the subservient, handmaidens frequently portrayed by social media, but instead, are knowledge, educated, and experienced professionals who should expect to be treated as such by other medical professional colleagues and the public.

Practice Environment

The nurse practice environment can be described as one of the most demanding work environments across multiple industries. Nurses experience violence in the workplace including; bullying, intimidation, physical assaults, threats, and verbal abuse. 1,3,4,5  The Joint Commission Sentinel Event reports highlight an ever-growing and serious threat of violence in the workplace and that healthcare organizations take critical measures to protect staff and patients.6  Research suggests 2/3 of the 1.5 million annual workplace violence incidents occur in the healthcare industry, and 30-50% of nurses experience assault at the practice environment.1  A 2006 report indicated that 86% of the 1000 emergency department nurses surveyed experienced workplace violence in the previous 3 years.1

Violence in the nurse practice environment is a sad reality for the nurse, the nursing profession, and the healthcare industry. Unfortunately, nurses frequently under-report incidences of violence; only a small percentage of nurses report assaults.1  Fear of retaliation, peer-pressure, job-loss, being labeled a trouble-maker or weak, and fear of further violence are real barriers to nurses. The impact of violence against nurses can be devastating personally and professionally.

Nurses who experience violence in the practice environment may demonstrate symptoms of fear, powerlessness, depression, stress, anger, anxiety, irritability, etc.1,3  Symptoms similar to post-traumatic stress disorder. Research indicates that nurses who are white, female, inexperienced, younger or older in age, and who have had experiences with childhood/partner violence tend to be at increased risk for workplace violence.1  The manifestations of violence against nurses is devastating and nursing leaders and healthcare organizations need to take steps to reduce violence by creating practice environments that promote conflict resolution, communication, collaboration, professional practice, and interdisciplinary relationships.3

Improving nurses’ perceptions of the practice environment is critical to the prevention of workplace violence. Relationships between the registered nurse and nursing leadership related to job satisfaction and perceived positive practice environments significantly impacts registered nurse job satisfaction levels.7  Strong nursing leadership is needed to create practice environments and work climates which are healthier and safer for both nurses and patients.8,9

Discontentment with the nurse practice environment is leading to a decline in nurse job satisfaction levels contributing to problems associated with the retention and recruitment of registered nurses.7  Multi-factorial influences are converging to create conditions for an unprecedented shortage of nurses.10  Without factoring in costs attributed to unexpected mortalities and complications, estimated turnover costs associated with the loss of one RN can range between 82,000 and 88,000 dollars.3,11  Nurses must advocate for practice environments which support their individual practices and prevent workplace violence.

Nursing Leadership

The identification of factors shown to influence the retention and recruitment of nurses is resulting in a shift in the relationship between the nurse and nursing leaders. Research suggests that there is a link between nursing leadership and nurse satisfaction and retention.3  Leadership attributes needed for the establishment of continuous learning and professional practice are critical to the role of the leader. Nursing leaders must be skilled at managing the staff and have the attributes necessary to create positive work cultures. The roles and responsibilities of nursing leaders, in particular front-line leaders, are dramatically changing.3  To be successful, nursing leadership practices that are built on de-centralized power concepts may be most effective given the flattening of organizational healthcare structures occurring today.3

Practice environment problems, including teamwork, collaboration, learning, professional practice development, resource availability, and work relationships must be addressed by nursing leadership.3,12  Nursing leaders are finding the need to develop the skills necessary to create positive practice environments to overcome workplace violence while promoting individual professional practice. Effective nursing leader attributes include; expert, advocate, arbitrator, supporter, communication/listener, accessible, and problem-solver.3,12 The relationship between the nurse leader and the nurse are critical to the advancement of healthy practice environments and nurse retention, satisfaction, and recruitment.

Time for Change

Nurses at all levels of an organization have a responsibility to their individual practices and the profession of nursing to create healthy practice environments. The days of perceiving the nurse as a lowly handmaiden are outdated and harmful to the discipline of nursing and the nurse. The call to nurses to stand together as healthcare professionals and to demand safe workplace cultures that are free of violence should echo the hallways of healthcare organizations everywhere. It starts with you; the educated, experienced, and independent healthcare professional who took an oath to protect and care for the public. Workplace violence must stop, and the nursing profession must change how nurses lead and practice. Nurse leaders must have the critical skills to create positive professional practice environments. Nurses can work collaboratively to create environments that promote learning, communication, and advocacy. Nursing leaders have a responsibility and a duty to institute policies, procedures, strategies, and safety measures to keep the workplace safe. As a result, nurses will once again engage in the concept of caring and embrace their passion for service by caring for the sick, injured, and underserved without the fear of violence.


  1. Valente S & Fisher D. Violence in the workplace. JOCEPS. Dec 2011;55(1):24-7.
  2. Summers S. The image of nursing: The handmaiden. Nurs Times. October 7 2010.
  3. Duffield CM, Roche MA, Blay N, & Stasa H. Nursing unit managers, staff retention and the work environment. J Clinical Nurs. 2010;20:23-33.
  4. American Association of Colleges of Nursing. The hallmarks of a professional nursing practice environment. AACN White Paper.
  5. Andrews DR & Dziegielewski SF. The nurse manager: job satisfaction, the nursing shortage and retention. J Nurs Manag. 2005;13:286-295.
  6. The Joint Commission. Safety event alert, issue 40: Behaviors that undermine a culture of safety.
  7. Zori S, Nosek LJ & Musil CM. Critical thinking of nurse managers. J Nurs Manag. 2010;42(3):305-313.
  8. Dierckx de Casterle’ B, Willemse A, Verschueren M, & Milisen K. Impact of clinical Leadership development on the clinical leader, nursing team and care-giving process: a case study. J Nurs Manag.2008;16:753-763.
  9. Rouse RA. Ineffective participation: reactions to absentee and incompetent nurse leadership in an intensive care unit. J Nurs Manag. 2009;17:463-473.
  10. Zolnierek C. Where did the nursing shortage go? Texas Nursing Voice. Jan/Feb/Mar 2011;5(6):6.
  11. Stone PW, Larson EL, Mooney-Kane C, Smolowitz J, Lin SX & Dick AW. Organizational climate and intensive care unit nurses’ intention to leave. J Nurs Adm. Jul/Aug Supplement 2009;39(7/8):37-42.
  12. Henriksen J. Exploratory Study of Nursing Leadership: Inquiry of Leadership Attributes of Nurse Managers in Acute Care Hospitals and the Professional Practice Environment.


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