The Problem with (un)Professionalism in Nursing CE Course

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This learning module aims to establish a complete understanding of desirable professional behaviors that nurses should be striving for while highlighting some of the most common unprofessional behaviors to avoid. 

By completing this educational activity, the learner should be able to: 

• recognize and apply the core principles in the American Nurses Association's (ANA) Code of Ethics in their daily nursing role and how this helps to define professional behavior 

• recall the importance of following the nursing process in the daily care of patients 

• employ standards of practice for self-care, communication, and responsibility for professional education and competence 

• discuss how nurses affect patient safety, manage fatigue, delegate appropriately, and participate in patient care on adjacent units (floating) 

• define disruptive and unprofessional behaviors in the nursing profession with everyday examples and associated legal risks 

• discuss and design ways to avoid excessive tardiness, absenteeism, disruptive behaviors, or medical errors 

• review how the nurse can positively impact sexual harassment, violence, incivility, and bullying within the healthcare industry 

• discuss how to recognize an unhealthy work environment and appropriate ways to self-terminate employment 

In recent years, there has been a renewed focus on medical professionals, including nurses, and their role in professionalism. Merriam-Webster (n.d.) defines professionalism as "the conduct, aims, or qualities that characterize or mark a profession or a professional person" (para 1). There is a saying that "professionalism is not just the job you do, it's how you do the job" (MindTools, n.d., para 2). The term professionalism describes an individual's behavior, dress, language (word choice), and affect. There are ten general characteristics of individuals that exhibit professionalism in the workplace (Piccirilli, 2018):  

• Professionals have a neat appearance by following good hygiene practices and coming to work dressed in clean, unwrinkled clothing.  

• They demonstrate a proper demeanor by speaking politely and calmly no matter the situation or person with whom they are talking.  

• They are reliable. They arrive to work on time, finish tasks and assignments at or before the deadline, and follow up on requests promptly.  

• They exhibit competence and continue learning by attaining professional designations or certifications, becoming experts in their field, and expressing confidence but not superiority.  

• Professionals communicate briefly and concisely with a polite and formal tone; they use a professional signature on emails and letters.   

• Their phone etiquette includes clearly identifying themself when speaking, listening intently, and avoiding interrupting or dominating the conversation.  

• Professionals are poised, maintaining composure and a level head and attempting to diffuse difficult and stressful situations; they do not mirror or provoke aggressive behavior.  

• They are ethical, always following the company or professional code of ethics at work and on personal time.  

• A professional is organized, keeping their area or desk neat and maintaining a calendar with deadlines, meetings, and appointments. 

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  They are accountable, taking responsibility for actions, owning up to mistakes, and not blaming others.  

Although professional behaviors should be maintained in all workplace environments, the recent push for remote at-home work has created a need to expand and better define remote workplace etiquette. These standards guide workplace behavior for employees who work from home and therefore never altogether leave their workplace, which often blurs the lines of work and home. Remote work from home is also expanding in the nursing field. When going from a hospital or clinic setting to a remote setting, there may be different norms that need to be understood to thrive in the remote environment. There are seven dos and don'ts for maintaining professional behavior in the virtual workplace (Potter, 2021):  

• DO set boundaries. As an employee, it is important to set personal boundaries of what will be considered after work hours. As a coworker, it is essential to respect the work-life balance of other colleagues and not send them emails or virtual chat messages outside of work hours. Any situations that would warrant an exception to the after-hours constraint would need to be agreed upon.  

• DON'T schedule unnecessary meetings. Similar to the sentiment of in-office work, no one wants to attend a meeting that could have been an email. Video meetings, in particular, tend to be distracting and more prolonged than necessary due to unintentional background interruptions.  

• DON'T forget about time zones. When interacting with coworkers or clients in various time zones, it is vital to be clear about deadline expectations and after-work hours. For example, an employee in California may submit work at 5 PM PST, but the deadline was 5 PM EST, therefore, missing the deadline.  

• DO reach out to new employees. It is even more important to get to know and welcome new hires in a remote environment. Take the time to reach out and get to know them. It may also help employees get to know each other if pictures are included in company profiles.  

• Do prioritize informal 'social' activities. Lasting connections between coworkers often happen outside of work. Coworkers have lunch together or go out after work to decompress. This type of interaction can be achieved, to a degree, by organizing informal video gatherings. It is essential not to make these feel mandatory.  

• DON'T forget the mute button. Just as it is not polite to interrupt someone speaking, it is very unprofessional to leave yourself unmuted during a video or conference call when you are not speaking. Since each individual is in a different location, being unmuted allows all the various background noises to come through and disrupt the person speaking.  

• DO feel their pain (have empathy). Understand that this time is stressful and challenging for everyone. Some people may be working remotely while their children are home, while others may be feeling isolated.  

There are also behaviors that remote workers can incorporate into their daily life to make working from home more successful. Some institutions have included these tips to succeed in their employee handbooks. First, it is important to maintain regular working hours and set boundaries between work and personal time. Maintain a morning routine. Just as an individual has a morning routine before leaving the house to work, maintaining that routine prepares the mind for the workday. Next, maintain a dedicated workspace or office and set boundaries with family members about entering the space during work hours. Household distractions should be kept to a minimum. Check-in with teammates and supervisors as expected to maintain contact and stay current on work projects. Set and keep a meal period and take short breaks at set intervals away from the desk to stretch, stand, and walk around throughout the day (Duffy, 2021).  

Professional Behavior 

As a student nurse, there is almost too much information to learn in a short time. Most nursing school programs focus undergraduate learning on anatomy and physiology, pathophysiology and pharmacology, and critical nursing skills. Professional behaviors are often not a priority, given the sheer volume of information to learn. However, these professional behaviors are crucial as new graduate nurses enter the nursing workforce. Professional behavior is not easily taught in textbooks and often requires effective role modeling in the clinical setting. Given the challenges of teaching professional behavior, many organizations have developed guiding principles, such as the American Nurses Association (ANA) Code of Ethics for Nurses (2015a). The ANA Code of Ethics lists nine provisions that nurses can use to help make decisions and guide their conduct as professionals (ANA, 2015a; Lockhart, 2017):  

• The nurse practices with compassion and respect for every person's inherent dignity, worth, and personal attributes without prejudice. This includes an expectation of respectful interactions and conflict resolution with colleagues and compassion and respect for the uniqueness of patients.  

• The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.  

• The nurse promotes, advocates for, and protects patients’ rights, health, and safety.   

• The nurse has authority, accountability, and responsibility for nursing practice, makes decisions, and takes action consistent with the obligation to promote health and provide optimal care. Accountability includes an expectation that nurses accept responsibility for assessing their competence and then seeking help, guidance, and further training or education when the current level of competence is lacking. 

• The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. This includes basic needs such as ensuring adequate nutrition and sleep and maintaining emotional and spiritual well-being as defined by the nurse.  

• The nurse, through individual and collective efforts, establishes, maintains, and improves the ethical environment of the work setting and the conditions of employment that are conducive to safe, quality health care. 

• The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.  

• The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.  

• The nursing profession, collectively through its professional organizations, must articulate nursing values, maintain the profession's integrity, and integrate principles of social justice into nursing and health policy). 

Professional organizations, certifying bodies, healthcare systems, and states and jurisdictions may also define professional behavior expected from nurses. For example, the state of Georgia specifies that nurses are expected to function within the legal boundaries of nursing practice, accept responsibility for actions and competence, communicate, collaborate, respect the dignity and rights of all patients, maintain their privacy, and assign only those tasks for which the nurse knows the other person is prepared, qualified, and licensed to perform (Georgia Secretary of State, 2019, section b).  

Ethical Behavior 

The ANA's revised Code of Ethics for Nurses with Interpretive Statements has specific provisions that apply to the professional conduct of the nurse. Provision 6 is often interpreted as nurses' responsibility to help create and maintain a safe and ethical work environment for themselves (Lockhart, 2017). Ethical practice is tied to standard 7 of the ANA's Scope and Standards of Practice (ANA, 2015d). Ethical principles that guide healthcare delivery by nurses can also help shape what should define professionalism. Once again, the ANA outlines basic ethical principles for nurses, including:  

• Autonomy and the right to self-determination establish the adult patient's right to make their own medical decisions as long as they are of sound mind. The nurse's role is to educate the patient and assist them in making the best possible decisions regarding their health and then respecting those decisions once they have been made.  

• Beneficence is the actions that promote the patient's well-being, including acting with compassion.  

• Nonmaleficence is the principle that guides nurses to choose interventions that inflict the least amount of harm to the patient while still being beneficial. 

• Fidelity is the principle that encourages nurses to be caring, loyal, honest, and altruistic in their care delivery. 

• Justice is the principle that compels nurses to provide equal care to all patients regardless of financial or social standing. 

• Paternalism is the principle that encompasses the power to intentionally reveal or conceal information to a patient or family regarding a diagnosis, treatment, or prognosis. The decision to either share or not share information with a patient or family is a careful balance of both options' potential benefits and risks (Davis, 2018). 

Other related ethical principles that should help shape a nurse's practice include disclosure (the moral obligation to disclose all necessary information to a patient to optimize informed decision-making) and veracity (providing accurate, complete, and unbiased information when asked; Sorrell, 2017). Industry standards highlight that nurses should care for patients regardless of their socioeconomic status (SES), personal attributes, or the nature of their health problems. However, in practice, the decision to act or not is often complicated and challenging to assess. The ANA offers the following checklist for nurses to use to evaluate their risk in caring for a patient:  

• if there is a significant risk to the patient if the nurse does not act 

• if the nurse's action is directly relevant to and will likely reduce the risk of harm 

• if the potential risk to the nurse by acting is not more than what is acceptable and will be outweighed by the benefit gained by the patient (ANA, 2015c) 

If the nurse can answer yes to these stipulations, they have a moral obligation to the patient to provide the expected care (ANA, 2015c).   

Self-care 

As stated in Provision 5 of the ANA Code of Ethics (2015a), self-care is an expectation of all nurses, and this may be the hardest for some to follow. Although nurses are very knowledgeable about health-promoting activities such as regular exercise, healthy eating habits, stress management, adequate sleep, and avoidance of alcohol and tobacco for their patients, most struggle with incorporating these things into their lifestyles (Ross et al., 2017). However, in light of the challenging 12-hour shifts and requirement for most inpatient units to be staffed around the clock, combined with the dangerous effects of fatigue and the high stakes at hand, the need for nurses to exercise self-care is essential. Studies have shown that nurse fatigue leads to suboptimal patient care, increased risk of medical errors or clinical decision regret, decreased functional or short-term memory ability, reduced learning ability, poor critical thinking skills, increased risk-taking behaviors, poor mood, reduced communication, and numerous physical health consequences (ANA, 2014). The fatigue and workload experienced by nurses can also lead to burnout, job dissatisfaction, and health consequences such as type 2 diabetes, cardiovascular disease, and obesity (Ross et al., 2017). Therefore, the ANA recommends that healthcare providers (HCPs), including nurses, limit their working hours to 12 in 24 hours and no more than 40 hours in 7 days. Over 40 hours in a week has been shown to affect patient safety and HCP health. The ANA also includes several other suggestions for the minimization of nurse fatigue and optimization of nurse performance, such as: 

• arrive for work alert and well-rested 

• sleep at least 7 to 9 hours in 24 hours 

• rest before the beginning of a shift 

• avoid medications that may cause drowsiness while working 

• communicate with coworkers at the beginning of the shift and devise a plan that ensures everyone gets the opportunity to take the suggested meal and rest breaks during the shift without compromising patient safety 

• maintain good general health by managing stress, maintaining good nutrition, and exercising regularly 

• ask your manager or supervisor for a copy of your institution's nap policy, as many hospitals have a specific policy to address this issue (ANA, 2014) 

Nurses not taking break periods during their shift has also become a professional norm, especially in acute care. A generally acceptable goal for a nurse is to take three 15-minute breaks and one meal break (typically 30 minutes) in a 12-hour shift. These recommendations are ideal and are not always possible, but they are more likely to be met through advanced planning and good communication among the nursing team. A recent survey of nurses in Seattle, Washington, found that every nurse surveyed missed at least ten breaks and two meals over two weeks. While this goal may seem difficult to achieve, adequate breaks are integral to nurse job satisfaction and retention (Patricelli, 2016). Some states have enacted laws surrounding break periods for HCPs working in hospitals to help empower nurses to utilize their break periods. For example, Washington State House Bill 1155 requires hospitals to provide nurses with scheduled uninterrupted breaks and meal periods and outlines proper off periods of at least 8 hours between shifts. The bill also eliminates mandatory overtime shifts and outlines limitations to on-call shifts used to circumvent mandatory overtime regulations (Washington State Hospital Association, 2019).  

Competence 

Completing a nursing program and successfully passing the applicable certification exam to practice, either the NCLEX-PN or NCLEX-RN, is considered the minimal competence level for a new nurse (Yoder, 2017). Provision 4 of the ANA Code of Ethics may apply to nurses starting on a new unit or in a new hospital or clinic. While the organization and leadership should design a comprehensive and relevant orientation program, the nurse is ultimately responsible for speaking up and seeking out any additional needed information that was potentially overlooked. Provision 5 includes the expectation for continued growth and professional development throughout the nurse's career (ANA, 2015a). It is suggested that nurses join a professional organization. There are numerous options for professional organizations at either the state or national level. Organizations also range from very broad, such as the ANA, to very specific, such as the Academy of Forensic Nursing (AFN). It is also recommended that nurses become certified. Although the process can be stressful, time-consuming, and expensive, it is an excellent way to demonstrate expert knowledge in a particular area. Most nurses blame the high cost with little to no incentive or pay increase as the most significant barrier to certification (Yoder, 2017). The expectation that nurses become lifelong learners and maintain knowledge and competence in current nursing practice is reiterated in standard 12 of the ANA's Scope and Standards of Practice (ANA, 2015d). 

Collaboration 

The nursing process can also help nurses determine what behavior is considered professional. The nursing process stipulates that a care plan is to be developed in step 3, the outcomes or planning step. In step 4, the implementation step, care should be implemented according to the care plan, ensuring continuity of care for the patient from hospitalization to discharge to the resumption of outpatient services. Establishing a care plan and following through are crucial for quality patient care. Once the appropriate care has been delivered, the nursing process highlights the importance of documenting the care provided (ANA, n.d.-b). Failure to follow standards of care and established protocols and document that care has been provided have been cited as leading causes of fault in nursing malpractice cases. Malpractice can be defined as negligence, misconduct, or breach of duty. (Perry, 2019).  

The ANA Code of Ethics (2015a) plainly states that the patient is the nurse's primary responsibility, so many professional behaviors are directly related to patient safety. As healthcare systems become more aware of unit culture’s effect on patient safety, the behaviors that positively or negatively impact that culture will become more scrutinized. Clear, open, and direct communication is of the utmost importance for patient safety. Ethicists suggest using handoff tools to help with clear and prompt nursing communication. When performing high-risk tasks such as medication administration, distractions should be minimized. Tasks should be simplified, procedures standardized, and supplies and thoughts organized to increase efficiency. Nurses are human at their core, and humans require help and built-in safeguards. Nurses should utilize checklists, reminders, double checks, computers, and technology to promote efficiency, improve accuracy, and reduce the risk of human error. When nurses are involved in shared governance and are brave enough to share their stories and experiences, their colleagues benefit from others' mistakes, and everyone learns. Being honest, especially when errors are made, can be scary in this modern litigious age of medicine. Still, studies have shown no link between a nurse's willingness to disclose errors and litigation. Nurses can affect culture even if they are not in leadership positions through leading by example (Davis, 2017; Sorrell, 2017). 

Another form of communication is delegation. Delegation is a skill that is honed throughout a career, just like any other nursing skill. Still, basic guidelines like those published in 2019 by the National Council of State Boards of Nursing (NCSBN) and the ANA can help graduate nurses develop this skill. The expectations of many nurses far exceed what a single person could hope to accomplish in a 12-hour shift, making delegation necessary for success and quality patient care delivery. The guidelines stipulate that delegating involves requesting a delegatee (whether a registered nurse [RN], licensed practical nurse [LPN], or unlicensed assistive personnel [UAP]) to perform a specific nursing activity that is outside their traditional role but within their capabilities. The delegatee must have demonstrated competence for the activity. The delegator (an advanced practice RN [APRN], RN, or LPN) maintains responsibility for ensuring the activity has been done completely and correctly. Activities outside the delegator's scope of practice or involving nursing judgment, assessment, or critical thinking should not be delegated (NCSBN & ANA, 2019). 

Floating occurs when one unit is overstaffed while another unit is understaffed. This means nurses who would typically provide patient care on a specific unit are assigned to provide care on a neighboring unit to cover staff shortages. While floating can be stressful, anxiety-provoking, and frustrating for some nurses, it is a basic form of resource sharing that institutions commonly employ. Floating can also be viewed positively as a refreshing change of pace that allows a nurse the opportunity to gain knowledge and build new skills. While a nurse has the right to reject or object, in writing, any assignment that endangers the patient, floating can be done safely and become a positive learning experience if specific steps are taken to ensure success. The Joint Commission (TJC) expects that a floating nurse should be placed on a unit of patients with comparable clinical diagnoses and acuities. The RN Safe Staffing Act of 2015 also states that hospitals are not to assign nurses to units for which they lack adequate experience, education, and training, such as specialty units. When floating to another unit, nurses should expect or request the following: 

• a brief orientation to the new unit, including any shift routines and the location of a break room, bathrooms, critical equipment (crash cart), medications, and patient care supplies 

• an introduction to an experienced nurse on the unit who may serve as a resource or partner throughout the shift 

• a written copy of contact information for unit resources, unit-specific documentation, and any written policies, procedures, or unit-specific clinical practices (O'Connor & Dugan, 2017) 

Finally, as a floating nurse, there should be support and encouragement for honest and open feedback at the end of the shift regarding what went well and what could have been made easier with specific and constructive suggestions without fear of retribution or judgment (O'Connor & Dugan, 2017). 

Unprofessional Behavior 

The attainment of professionalism is often more clearly understood when examples of unprofessional behavior can be used to explain what not to do. Common unprofessional behaviors that should be avoided in any professional environment, healthcare not excluded, include: 

• missing a deadline (an example for nurses would be consistently administering patient medications behind schedule or not carrying out an order within a specific time frame) 

• not being forthright or withholding information (for example, not reporting an error to a manager as soon as possible or not communicating with the care team about a change in patient condition) 

• not being forthcoming about a conflict of interest (for example, an individual working for two competing companies and not disclosing that information to their direct supervisor)  

• not respecting privacy or need-to-know patient information (sharing patient information with others inappropriately or not destroying identifying patient materials correctly) 

• plagiarizing or taking credit for someone else's work (for example, copying and pasting chart and assessment data)  

• failing to accept responsibility or passing blame to others 

• exaggerating qualifications or past experiences (for example, lying on a resume or telling a preceptor that you have completed a skill competently that you have not) 

• frequently changing jobs 

• a sloppy or unkempt appearance (arriving at work with dirty or wrinkled clothing or not practicing good hygiene; Purdy, n.d.) 

Within healthcare, there may be additional specific inclusions related to unprofessional behavior. For example, the state of Georgia provides an excellent balance to their definition, as mentioned earlier, of professional behavior for nurses by providing the following items considered unprofessional behavior: 

• inappropriate or unsafe judgment 

• abandoning or neglecting patients 

• providing false or misleading information 

• accepting a patient assignment that is unsafe 

• accepting a task that is outside of the nurse's scope of practice 

• failing to maintain accurate documentation 

• drug diversion 

• arriving to work or working while under the influence or otherwise impaired 

• failing to maintain professional boundaries with a patient or patient's family member 

• threatening or violent behavior (Georgia Secretary of State, 2019) 

 Consequences of Unprofessional Behavior 

Unprofessional behavior in the workplace, including healthcare settings, can have far-reaching consequences. When unprofessional behavior is the workplace norm or is allowed to continue by leadership, the result can be decreased staff morale, absenteeism, a hostile work environment, and increased turnover. These behaviors can also increase medical errors, adverse events, and patient mortality. In addition, when individuals work in a hostile or unprofessional work environment, they may feel isolated, uncertain, depressed, angry, or fearful while working. These feelings can lead to physical manifestations such as insomnia, fatigue, headaches, and nausea. When an individual is experiencing all these physical and emotional effects, their ability to think clearly, make critical judgments, and voice concerns diminish, resulting in consequences on patient care and outcomes (Grissinger, 2017).  

 Errors 

While errors are a normal part of human existence, for a nurse, some errors can be deadly for the patient. According to Rodziewicz and colleagues (2022), over 100,000 deaths occur annually due to preventable medical errors. This makes medical errors a leading cause of death (Rodziewicz et al., 2022). A key element in patient safety involves fostering a blame-free environment of interdisciplinary teamwork (Agency for Healthcare Research and Quality [AHRQ], 2019). It has been found that most medical errors occur because of broken systems and processes within the institution or workplace. Studies show that the highest rates of medical errors occur in intensive care units (ICUs), emergency departments (ERs), and operating rooms (ORs). Errors can be prevented by implementing safeguards and setting up a workflow to make it hard for the individual to make mistakes. Some of the most common and most dangerous nursing errors and how to avoid them include (Carver et al., 2021; Eastern Michigan University, 2020):  

• Medication errors include not diluting a medication before administration, administering medication via the wrong route, giving the wrong dose, or mixing incompatible medications. Avoid distractions during medication administration. Always use the "8 rights" (right patient, right time, right drug, right dose, right route, right reason, right documentation, and right response). Do not hesitate to ask questions or double-check something, especially if it looks different or incorrect to you. There is estimated to be one patient death per day in the United States alone due to medication errors.  

• Falls can cause patients physiological harm and psychological distress, increasing their anxiety and thus increasing their risk for future falls. Nurses can limit the risk of falls by educating patients about calling for help, performing hourly rounding to check on patients frequently, and implementing safety features such as non-slip socks, bed alarms, and posted signs alerting staff and family members when a patient is at increased risk for falls.  

• Infections that develop while the patient is admitted to the hospital are called hospital-acquired infections. Common examples of hospital-acquired infections include catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated pneumonia (VAP). Hand hygiene is the most effective way that nurses can limit the risk and spread of hospital-acquired infections, in combination with sterilizing equipment and good aseptic technique. 

• Documentation errors include incorrect abbreviations, charting under the wrong patient, and dictation and transcription errors. The adage in healthcare also rings true today: if you did not document it, it did not happen. Be sure all interventions are documented along with the time they were completed. The same principle holds for interventions that were not completed. Be sure to document why a particular intervention was not carried out as ordered (for example, why the patient refused a medication). 

• Nurses should know the correct body mechanics to safely transfer, lift, turn, and move a patient. Many hands make light work, so asking for help from colleagues and coworkers decreases the risk of injury. Appropriately using assistive equipment such as a mobility-promoting support aid (e.g., a sera stedy), a patient lift (e.g., sit to stand, overhead, or sling), or a transfer device (e.g., a slide sheet) when available can also decrease the risk of injury. 

• Being unfamiliar with equipment can lead to both patient and staff injury. Nurses should familiarize themselves with all available equipment in their daily environment, ask for training or in-services if additional instruction is needed, and always use the equipment as intended. 

• Failure to prioritize tasks or the inability to complete tasks promptly can lead to errors. Nurses are often reluctant to ask for help, but no one is an island. Nurses should ask their colleagues for help, delegate tasks to UAPs, and offer to help them in return. HCPS should work as a team, and if unsure about something, ask the charge nurse, manager, or supervisor for guidance  

In addition to having grave consequences for the patient, errors can also lead to malpractice and other legal issues for the nurse. The most common reasons that nurses are found at fault include failure to assess or monitor a patient, follow standards of care or protocol, responsibly use equipment, communicate effectively, document thoroughly, act as a patient advocate, follow the chain of command, or respect privacy (Perry, 2019). 

Disruptive Behavior  

Unfortunately, disruptive behavior is common in healthcare, despite the Nurse's Bill of Rights clearly stating that all nurses have a right to a safe, supportive, and ethical work environment (ANA, n.d.-a). The AHRQ (2019) defines unprofessional or disruptive behavior as "any behavior that shows disrespect for others, or any interpersonal interaction that impedes the delivery of patient care" (para. 2). This may include behavior that is demeaning or harassing. Although the common stereotype of disruptive behavior involves a physician as the instigator, a recent survey showed that 65% of respondents had witnessed disruptive behavior by nurses. This behavior increases the risk of medical errors, adverse events, and deaths (AHRQ, 2019). In addition, the ANA cites disruptive behavior as a known cause of decreased job satisfaction, worsened personal health, additional healthcare costs, and overall decreased patient safety (ANA, 2015b). JCAHO's code of conduct instructs healthcare organizations to adopt a zero-tolerance policy for disruptive behavior. Nurses can actively discourage disruptive behavior by modeling healthy communication as described above and by addressing and reporting disruptive behavior immediately if witnessed (AHRQ, 2019). In their recently published position statement on incivility, bullying, and workplace violence, the ANA (2015b) defines incivility as rudeness, gossip, or refusing to assist coworkers. The ANA places the responsibility on nurses to treat colleagues, coworkers, employees, employers, students, and others with respect and dignity. All nurses should take the time to review the ANA's complete list of recommendations for nurses in the full position statement (ANA, 2015b). 

An especially troubling aspect of disruptive behavior is violence, either physical or non-physical (which includes incivility and verbal abuse), and sexual harassment. When these acts occur at an individual's place of work, it is defined as workplace violence. When nurses exhibit these behaviors against each other, it is known as lateral or horizontal violence. Lateral or horizontal violence and the negative interactions between nurses are well known and have been extensively researched and reported. Lateral or horizontal violence occurs most frequently in ICUs and ORs (7.4%) and long-term care units (7.0%). Lateral or horizontal violence can have significant consequences for nurses in their work environment and personal lives. One study found that 36.5% of nurses report being exposed to physical violence, and 67.2% report non-physical violence from patients in the workplace. This is compared to the 87% that reported experiencing lateral or horizontal violence and 81% that reported bullying. In addition, 75% of nurses reported experiencing emotional and physical effects from their work environment (Bambi et al., 2018).  

Lateral or horizontal violence is most commonly non-physical violence manifesting as psychological harassment. Behaviors of harassment include threats, embarrassment, exclusion from both social and professional events, intimidation, and use of sexual innuendos. These behaviors can manifest as withholding vital information, unauthorized use of personal belongings, eye-rolling, use of sarcasm, and rudeness. There is a difference between bullying and lateral or horizontal violence. One difference is the frequency of the behavior. Lateral or horizontal violence typically occurs infrequently or as an isolated incident that is never repeated. Bullying is an enduring behavior repeated at least weekly but often more frequently for more than 6 months. Another difference is that bullying behavior is offensive, insulting, and malicious. The literature has shown that lateral violence in the workplace leads to disengagement, retaliation, absenteeism, poor job satisfaction, and high turnover rates. There is also evidence that individuals experience decreased self-confidence and increased risk for cardiovascular disease, psychological symptoms, psychosomatic disorders, and chronic illness resulting from bullying (Bambi et al., 2018). Please see the NursingCE course Fostering Civility and Healthy Work Environments for more information on this topic. 

The other type of workplace harassment is sexual harassment. Sexual harassment is defined by the U.S. Equal Employment Opportunity Commission (n.d.) as harassment directed at an individual because of their sex. It may include unwelcome advances, requests for sexual favors, verbal harassment, physical harassment, or offensive remarks about a person's sex. By definition, it must be severe or frequent enough to create a hostile work environment or result in an adverse employment decision such as a demotion, termination, or lack of promotion. It can be directed at or committed by a coworker/colleague, boss, employee, or patient (U.S. Equal Employment Opportunity Commission, n.d.). Please see the NursingCE course on Sexual Harassment Prevention for more information on this topic. 

Absenteeism  

Absenteeism and tardiness in nursing are especially destructive as these behaviors are unprofessional and directly impact patient care, patient safety, and the happiness and respect of colleagues and coworkers. If a nurse calls at the last minute to inform the manager that they cannot work, another nurse may have to work overtime, or multiple nurses on the unit may have to care for more patients than usual during that shift. If a nurse arrives late, the nurses who have been caring for their patients may not be able to leave work on time and may receive reprimands from management for accruing too much overtime while waiting for the late nurse to arrive. USLegal (n.d.) defines absenteeism as an unscheduled absence from work due to illness, a family or household emergency, or the death of a close friend or relative. They define excessive absenteeism as three or more episodes of absenteeism in any 90-day period. According to the U.S. Department of Labor, absenteeism accounts for over 2.8 million lost workdays per year. Due to this, many businesses have been forced to build in a 10-20% staffing buffer to cover the gaps created by absenteeism (USLegal, n.d.). In general, absenteeism leads to decreased performance and increased costs. Absenteeism affects staffing ratios, lowers staff morale, increases workloads, decreases productivity, disrupts workflow, creates job dissatisfaction, and directly and indirectly decreases the quality of patient care. The irony in this situation is that the increased workload and reduced job satisfaction further increase absenteeism, creating a vicious cycle (MasterStreet, 2018; Ticharwa et al., 2019).  

Illness or injury is the most common reason for absenteeism, and in nursing, this is often a valid and reasonable occurrence. Arriving to work sick risks spreading the illness to patients and coworkers and endangers patients further by increasing the risk of errors or safety events due to the nurse functioning at sub-optimal levels secondary to illness. However, good self-care and safe lifting practices can mitigate the risk of illness and injury. Other reasons commonly cited for absence include transportation and childcare issues and the death of a family member. While a short leave of absence to attend a family member's funeral is reasonable and expected, especially for immediate family members, unexpected absences for transportation and childcare issues can often be avoided by ensuring reliable forms of both and contingency or backup plans are considered in advance. Avoiding double shifts and other forms of overtime has also been shown to decrease absenteeism (MasterStreet, 2018; Ticharwa et al., 2019). 

Retention  

Unprofessional behavior decreases employee satisfaction leading to high staff turnover rates. According to Alexis and colleagues (2020), retaining staff saves the institution money on recruitment, orientation, and supplemental staffing. Lockhart (2020) explains that 18% of new nurses change jobs or leave the nursing profession within one year of graduation. Over two years, that rate increases to 33%. The 2022 NSI National Health Care Retention and RN Staffing Report states that the nursing turnover rate is currently 27.1%, an increase of 8.4% from the previous year. Hospitals located in the Southeast region of the US reported the highest turnover rate at 29.9%. In comparison, hospitals located in the West region reported the lowest turnover rate at 23.8%. The cost to replace a bedside RN ranges from $28,400 to $57,700 and averages $48,038. The current turnover rate for nursing staff can cost an institution up to $9 million every year. Despite all this money spent on recruiting and training, 31.7% of new hires leave their position within the first year, and 54.5% leave within the first two years (NSI Nursing Solutions, 2022).  

Nurses report a variety of reasons for leaving their current position, including relocation, career advancement, retirement, education, working conditions, salary, and scheduling. Currently, it is unclear if an increased number of nurses are retiring due to the aging nurse workforce or the current working conditions surrounding COVID-19. Certain specialties are experiencing turnover rates well above the national average. The three specialties with the highest turnover rates include intermediate/telemetry units (30.2%), behavior health (23.4%), and emergency medicine (29.7%). This equates to each department replacing its nursing staff every five years. By contrast, women’s health (19.5%) and surgical services (18.8%) have the lowest turnover rates (NSI Nursing Solutions, 2022).   

The current national vacancy rate of nursing positions rose 7.1% from 2021 and is currently 17%, with 81.3% of hospitals reporting a vacancy rate over 10%. Due to COVID-19, the cost of agency nurses is skyrocketing, with rates increasing weekly. Currently, hospitals spend 62.5% more on travel nurses than in 2020. It is estimated that for every 20 travel nurses used to fill vacancies, the cost to the hospital is approximately 4.2 million dollars. Agency staff is often used temporarily to fill vacancies. Depending on the specialty, it takes 66-126 days to recruit a new nurse, and these numbers have continued to increase since 2020. For example, it took 91 days to recruit a critical care nurse in 2021; in 2022, it took 96 days to recruit for that same position (NSI Nursing Solutions, 2022).   

There are things that healthcare institutions can do to increase retention rates. Shift length is often cited as a cause of nursing turnover. Institutions that schedule nurses for 12-hr instead of 8-hr shifts have increased difficulty with retention. Changing shift length back to 8-hr shifts may increase nurse satisfaction. Other causes of turnover include peer relationships and unit culture, which can be influenced by staff behavior. It is also essential to support new graduates and new hires during the first year of work, as these nurses account for a large percentage of nurse turnover (Lockhart, 2020).  

Minority or Marginalized Populations 

As the workforce diversifies, women and minority groups (based on gender identity, sexual orientation, race, and ethnicity) must adhere to non-inclusive professional norms or standards. As discussed above, professionalism describes a professional's ideal characteristics and behaviors, such as appearance, dress, language, and etiquette. Based on these historic, non-inclusive standards, some individuals may be deemed unprofessional based on appearance (e.g., hairstyles or head coverings) or language (e.g., different formality standards or English as a second language). Individuals who identify as a minority or a member of a marginalized group experience unprofessionalism differently than the majority. These individuals have expressed a more significant infringement on their professional boundaries in the workplace. This unprofessional behavior takes the form of microaggressions, racism, xenophobia, sexism, homophobia, bias, harassment, and discrimination. There are also accounts of professional standards being applied differently to those that identify as belonging to a marginalized population. Due to these differences in treatment, marginalized individuals do not feel supported in their workplace, leading to turnover. In one study, only 52.4% of female staff, 58.2% of non-Hispanic Black staff, and 54.8% of LGBTQ staff reported that their employer supported a culture of professionalism. This indicates that the other half felt that professionalism was not a priority for their current employer. That same study found that 14.3% of females, 14.8% of non-Hispanic Black individuals, and 15.5% of LGBTQ individuals have considered a job change due to a coworker or supervisor exhibiting unprofessional behavior (Alexis et al., 2020).  

According to Lockhart (2018), the following signs may identify a 'toxic culture' or unhealthy work environment that nurses should look for:  

• abuse of position and power  

• unmotivated and disengaged staff 

• lack of transparency and honest communication  

• poor mentoring and training  

• no work-life balance or respect for personal time  

• poor patient outcomes 

• high turnover and employee illness (absenteeism)  

• discrimination 

• favoritism (Lockhart, 2018) 

So, what if a nurse finds themselves in an unacceptable position despite their best efforts? Is it simply time to move on to the next great adventure? Giving notice of self-termination should be done professionally. Giving ample notice is a sign of respect to the manager, coworkers, and patients. While two weeks is the legal minimum in most cases, employers may specify that more time is needed to advertise, interview, and train a replacement for the current role. Leaving without sufficient notice eliminates the ability to utilize the current employer as a positive professional reference in the future and puts other nurses and patients at risk. Ideally, nurses should give as much notice as possible, such as four weeks. The decision to self-terminate should be communicated face-to-face in a direct, honest, and concise manner, often with a formal written letter in email or paper form if needed for Human Resources. If there is criticism, this should be delivered objectively, truthfully, and respectfully. The departing employee should express gratitude for the experience and opportunity and fulfill all existing commitments before the last day. Human Resources often conducts anonymous exit interviews to allow an additional opportunity for constructive and transparent feedback (Hamstra, 2018). The recent 2022 Gallup poll found that for the 20th year straight, the American public rated nurses as the most honest and ethical profession (Saad, 2022). However, as Spider-Man taught us, with great power comes great responsibility. Let's ensure that we strive to maintain and honor that trust daily as nurses. 

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