Date of Submission

Winter 12-9-2021

Document Type


Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Dr. KT Waxman

Second Advisor

Dr. Elena Capella


Background: Nurse leaders must create a collaborative work setting to promote a healthy work environment (HWE). The Joint Commission reported in 2014 that 71% of physicians and nurses reported disruptive behavior was linked to medical errors. The culture of a team sets the foundation of safety for patients and nurses. A HWE is necessary to ensure agility, progress and effectively strive for zero harm. Nurse executives are challenged to empower front-line leaders to create a HWE conducive to open communication, psychological safety and results in a setting where employees can thrive.

Problem Description: There is an epidemic of bullying and incivility in nursing and an urgent need to improve culture in healthcare throughout the nation and across the globe. The increased demands and decreasing resources create an environment ripe for incivility and bullying. Incivility and disruptive behavior are known to impact safety and patient care. The Joint Commission called for healthcare systems to address teamwork, communication, and commitment to a zero-tolerance of disruptive behaviors when they issued the Sentinel Event Alert 40: Behaviors that undermine a safety culture. This project aimed to improve the confidence and competency among frontline nurse leaders to address disruptive behaviors and strengthen a healthy work environment. Frontline leaders were provided an opportunity to complete the Eradicating Bullying and Incivility (EBI) course, improve their transformational leadership style and apply high-reliability tenets to create a HWE following a baseline assessment throughout a four-phased educational program.

Methods: The data evaluated throughout this project included leadership confidence to address disruptive behavior, nursing-sensitive indicators, and staff perception of culture. The Healthy Workforce Institute's Disruptive Behavior Survey (HWI-DBS) was utilized to collect initial data and consecutive data points at six-month intervals a total of three times. The HWI-DBS is a valid, reliable instrument that measures staff relationships with physicians, leaders, and staff culture. The EBI pre and post-tests included self-assessment appraisals of participants to compare leadership confidence in addressing disruptive behavior. Additional data analyzed includes nursing certification and nursing-sensitive indicators.

Interventions: The educational program includes collaboration with a subject matter expert, Dr. Renee Thompson, on incivility and bullying, implementing a high-reliability strategy focused on improving workflows and system opportunities, simulation settings where leaders can hone their newly learned skills, leadership coaching and mentoring, and collaborative forums to create new department norms in alignment with the vision of a healthy work environment (see Appendix A). The EBI leadership course provided five modules of new content and educational material for front-line leaders: getting clear on bullying, recognizing disruptive behaviors, setting behavioral expectations, confronting disruptive behaviors, and holding employees accountable (Thompson, 2019). The EBI course was held from January 2020 through February 2020. The EBI course provided leadership preparation through didactic modules, cohort-guided discussion, and coaching calls. Following the leadership completion of EBI, the teams embarked on the four-phased Deep Cultural Change Initiative (DCCI) educational program. The DCCI program launched in February 2020 across three patient care services departments and transitioned to the sustainability phase in May 2021.

Results: Statistical analysis for overall nurse leader self-assessment showed an average of 72.2% improvement from baseline (N=13) utilizing the EBI leadership assessment instrument. Statistical analysis for DCCI shows an overall improvement of 5.8% in leadership relationships and a 4.9% improvement in team culture, exhibiting an increased perception of healthy relationships. A .8% improvement in physician relationships exhibited improved healthy interactions between staff and physician. Nursing-sensitive indicators were compared utilizing a Safety Priority Index (SPI) rate and showed an improvement from .82-.68, exhibiting a decrease of patient harm of 17%. National nurse certification increased from a baseline pre-intervention of 86 certified nurses to a total of 256 certified nurses a year to date in 2021, exhibiting a 198% increase in nurse certifications.

Conclusions: The HWI-DBS total mean score for leadership relationship improved from pre-intervention (M=71.1%) to post-intervention (M=76.9%). The HWI-DBS total mean score for overall department culture improved from pre-intervention (M=76.4%) to post-intervention (M=81.3%). The total mean score for physician relationships improved from pre-intervention (M=21.5%) to post-intervention (M=20.7%), with a decrease exhibiting decreased incidence of disruptive behaviors experienced or witnessed between physicians and staff. Post EBI course completion, participants improved in their self-assessment of confidence and competency from preintervention (M=92, N=13) to (M=158, N=13). The scores reflect the value of investing in leadership growth, development, and tools to create a HWE.

Included in

Nursing Commons