"Nurses eat their young." "Grow a thicker skin." "Nursing's always been like this—it's just the way it is."

Sadly, most nurses hear phrases like these before they even graduate from nursing school. It’s expected that new nurses will experience some type of 

, physicians, and even from their managers as they transition from the classroom to the floor. There is also the unspoken expectation that nurses should just put up with it and deal with it. Countless nurses stay quiet about this insidious type of workplace behavior because, in many cases, speaking up leads to more problems.

Bullying has been accepted for decades as a part of the culture of nursing. It’s viewed as part of the rite of passage from student nurse to professional nurse. Now, older, more experienced nurses are becoming the targets of bullying from younger nurses who are trying to assert dominance in a progressively chaotic and stressful healthcare workplace. Regardless of age, nurses worldwide are being confronted with this dangerously toxic form of intimidation, ultimately affecting their confidence, happiness, and ability to practice nursing safely and competently.

Bullying isn’t confined to the United States. Globally, it’s reported that about 37% of nurses experience some form of bullying.

 Different from isolated violent incidents, workplace bullying among nurses is defined as a variety of subtler, but sabotaging, behaviors that occur over a time period of at least 6 months.

 These behaviors are used to destroy a nurse’s credibility and confidence.

 Bullying includes, but is not limited to, infighting, intimidation, scapegoating, passive aggressiveness, excessive criticism, and withholding assistance.

Bullying in the workplace is one of the main factors behind nurse burnout and increased rates of staff turnover.

The impact of bullying on nurses, both young and experienced, is increasingly well documented. Bullying in the workplace is one of the main causative factors in nurse burnout and increased rates of staff turnover. This leads to increased operating costs for healthcare systems due to absenteeism, staff replacement, and mediation and arbitration.

 Perhaps most disturbingly, there is mounting evidence demonstrating the relationship between nurse bullying and negative patient outcomes. Bullying in the workplace has been shown to decrease the quality of care patients receive, causing a very real threat to patient safety and reducing the likelihood of positive patient care results.

Ineffective nurse leadership contributes to the problem of bullying. Many nurses describe a lack of managerial support and intervention for situations involving bullying.

 Even when nurse managers listen to complaints about bullying, often little or no action is taken to resolve the situation.

Research has identified several managerial problems, including nurse leaders who use silence, censorship, and self-protection tactics as methods of avoiding the problem of nurse bullying.

 Further, management that is either unfair or unpredictable has been shown to be the strongest predictor of workplace bullying.

 Renee Thompson, DNP, RN, CMSRN, a leading authority and speaker on nurse bullying, describes the problem: “What is sometimes shocking to me is how leaders just turn a blind eye. Leaders use silence as a strategy. Nobody’s addressing it. Everybody knows it’s happening, but nobody’s doing anything about it.”

“You have a lot of nurses who are excellent clinicians...but they’re toxic to an organization. What happens is, leaders justify it, they ignore it, or they sweep it under the rug. I’ve talked to many leaders who say a particular nurse is so good, they are so competent, and the patients love them. However, if you can’t keep [other] nurses employed on that unit because of that 1 toxic nurse, that nurse needs to go. It doesn’t matter how clinically competent they are,” says Thompson.

“Bullying has to be attacked from multiple levels,” explains Thompson. “First, you need leadership commitment—an executive leadership team that takes a stand on this. You also need frontline managers, those who are responsible for the day-to-day operations and the behaviors of their employees, to be provided the

 they need to develop the skills to be able to address destructive behaviors.”

 has set a “zero tolerance” policy for workplace violence and bullying from any source, and its “Incivility, Bullying, and Workplace Violence” resources include downloadable graphics spotlighting best practices for preventing bullying and promoting civility, handbooks, and tip cards on how to respond to bullying in the workplace.

launched an online Workplace Violence Prevention Resources Center last fall, following research, including a 2014 Health Risk Appraisal by the American Nurses Association, which found that 21% of registered nurses and nursing students reported being physically assaulted, and more than 50% were verbally abused within a 12-month period.

  provides an array of resources, articles and blog posts from author, speaker, and anti-bullying expert Renee Thompson, DNP, RN, CMSRN. 

Indeed, effective nursing leadership may be the missing link in the successful mitigation of bullying,

 but a substantial barrier to more effective nurse management is education. Education to develop leadership and management skills must be provided in order to create healthy work environments,

 but training programs that actually address workplace bullying are lacking.

“In my experience, I’d say 95% of all managers have never been trained on how to deal with bullying behavior,” Thompson noted. “There needs to be curriculum for leadership development that’s specific on how to deal with disruptive behaviors. We need to do a much better job supporting frontline managers and teaching them how to set behavioral expectations, hold people accountable, and confront bullying behavior.”

Many nurses and nurse leaders are currently working to stop the cycle of bullying, but it is difficult due to the pervasiveness of the problem. Communication techniques, conflict management skills, and positive self-care activities can be taught to individual nurses, but without both individual and managerial interest and investment in such programs, the problem of nurse bullying will only continue to worsen. As Thompson stressed, “There needs to be individual, practice-wide accountability. Eliminating bullying isn’t just the boss’ job. It’s everybody’s job.”

1. Spector PE, Zhou ZE, Che XX. Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: a quantitative review. 

. 2014;51(1):72-84. doi: 10.1016/j.ijnurstu.2013.01.010.

2. Simons SR, Mawn B. Bullying in the workplace—a qualitative study of newly licensed registered nurses. 

. 2010;58(7):305-311. doi: 10.3928/08910162-20100616-02.

3. Hutchinson M, Hurley J. Exploring leadership capability and emotional intelligence as moderators of workplace bullying. 

. 2013; 21(3):553-562. doi: 10.1111/j.1365-2834.2012.01372.x.

4. Rocker CF. Responsibility of a frontline manager regarding staff bullying. 

5. Gaffney DA, Demarco RF, Hofmeyer A, Vessey JA, Budin WC. Making things right: nurses’ experiences with workplace bullying—a grounded theory. 

. 2012;2012:243210. doi: 10.1155/2012/243210.

6. Lux KM, Hutcheson JB, Peden AR. Ending disruptive behavior: staff nurse recommendations to nurse educators. 

 2014;14(1):37-42. doi: 10.1016/j.nepr.2013.06.014.

Articles

No longer simply accepted as part of the culture of nursing, bullying must be acknowledged and addressed. It starts with education and a commitment to a healthy work environment.

Zero Tolerance: Stopping Nurse Bullying Begins With Leadership

Many cases of sepsis are discovered in inpatient settings as comorbidities occurring with other, more prominent medical issues. Frequently diagnosed in ICU settings, sepsis has usually progressed past its early stages once identified. Patients with cancer are at particularly high risk for developing sepsis, and severe septic infections are a factor in at least 8.5% of all cancer-related deaths.

Sepsis risk in the oncology setting is due to a variety of factors. Frequent hospital stays, surgeries, catheter insertions, and other procedures all increase the risk. These patients also already have depressed immune systems and are likely malnourished and frail as a result of treatments and therapies.

It is vitally important that sepsis be diagnosed as early as possible to ensure immediate, appropriate treatment. However, sepsis is usually diagnosed only after patients arrive at hospitals, when critical treatment windows might have already passed.

With so many patients arriving to inpatient facilities with severe sepsis, there is clearly a need for protocols and procedures to help with identification of sepsis in ambulatory facilities, where nurses are on the frontlines of healthcare and in a prime position to recognize sepsis and refer patients for immediate treatment.

According to the Sepsis Alliance, more than 1.6 million Americans, including many patients with cancer, are diagnosed with sepsis every year,

 but significant obstacles to early sepsis recognition remain after these patients are discharged from acute care facilities.

Septic infections begin outside of the hospital for nearly 80% of patients,

 but the public is generally unfamiliar with sepsis as a medical condition; in fact, only 55% of American adults have even heard of it.

 Lack of community awareness presents a huge hurdle to effective sepsis management and can have severe implications for patients with cancer when they return home. Patients and families might receive sepsis education before discharge, but there is no guarantee that the information, if provided, will be effective in illustrating the necessity of sepsis monitoring and the need for urgent treatment if symptoms develop.

Healthcare provider familiarity with sepsis is also an issue, suggesting a need to educate nurses, physicians, and emergency medical technicians on the signs and symptoms of early sepsis. Sepsis, by its very nature, looks like many other diseases. Since many of the early signs of sepsis could apply to a variety of other conditions or diseases, it is especially hard to diagnose.

Sepsis screening tools and bundles have been around for about a decade,

 but these are not commonly utilized in outpatient settings. Nurses might not even know what symptoms of early sepsis to look for in patients with cancer.

As Laura Messineo, RN, MHA, and Sepsis Alliance Board Member explained, “There is a lack of screening in the [outpatient] environment. How many patients come in that have some source of infection, and are [providers] really looking for any kind of systemic inflammatory response out of these patients? I think the core problem is that we aren’t screening for it.”

“Nurses don’t necessarily come out of school with a comprehensive understanding of sepsis,” she continued, “and that really leaves it on the employer, whether in the acute care setting, the outpatient setting, or skilled nursing facilities. I do believe there’s a need for ongoing education in whatever setting nurses practice in.”

) has valuable resources for patients and healthcare practitioners, including handouts and patient education counseling points, along with a special “Nurses Know Sepsis” series, featuring first-person nurse-focused case examples describing their clinical experiences with sepsis.

Seven in 10 patients with sepsis have recently used healthcare services or have chronic conditions requiring frequent medical care,

 and nurses in oncology outpatient settings are in a unique position to educate and screen patients for signs of sepsis.

Current efforts in inpatient settings to develop sepsis screening tools could be applied in the outpatient setting. Several healthcare facilities across the nation, including the University of San Francisco Medical Center, Banner Health, and Presence Health, are developing sepsis screening tools that continually evaluate patient data as it is populated into electronic health records, flagging those patients most at risk for developing sepsis for more careful monitoring.

“There is great opportunity to transfer this type of screening process to the outpatient setting. If you really think about the outpatient setting, the question of, ‘Does the patient have infection, or is there suspected infection?’ becomes important,” said Messineo.

“If we could hardwire sepsis screening into outpatient settings, I think we could catch more patients that are heading toward severe sepsis, and get them the right treatment, so they don’t escalate to septic shock and acute care treatment. There should be actionable steps taken by clinicians for those patients who are identified,” she continued.

Bigger organizations are also working to expand the healthcare provider knowledge base regarding sepsis. The Sepsis Alliance is currently “working on lots of different educational tools for all settings that have recorded dialogue so you wouldn’t actually need a physical person coming out there to provide education. The same message would get to every clinician.”

Resources are geared toward clinicians and patients to aid in the identification of early sepsis. Additional efforts to increase public and provider awareness of sepsis and its early signs continue in the community outside of healthcare facilities.

“I started seeing, on social media alone, patients saying ‘I never knew what [sepsis] was. If I knew the signs, I would have come in for treatment,’” said Messineo. “That really started a movement to increase awareness through special community events. One is a 5K that is solely focused on bringing healthcare clinicians and our community together to recognize those early sepsis warning signs.”

Because so many patients die from septic infections, it is more crucial than ever for healthcare providers, patients, and their caregivers to receive education so they can recognize the early signs—especially outside of acute care facilities. Nurses are in a unique position to educate patients with cancer and their families, but they have to have adequate knowledge of sepsis personally before meaningful education can occur.

“These patients should be armed with this information. Many times, oncology patients die of sepsis and not the actual cancer. We know that sepsis is the third leading cause of death in the United States, so there should be just as much focus on sepsis as there is on heart disease or stroke,” Messineo concluded.

Williams MD, Braun LA, Cooper LM, et al. Hospitalized cancer patients with severe sepsis: analysis of incidence, mortality, and associated costs of care

Seymour CW, Rea TD, Kahn JM, et al. Severe sepsis in pre-hospital emergency care. 

CDC Vital Signs. Making Health Care Safer. Think sepsis. Time matters. 

ECRI Institute. Sepsis: Combating the Hidden Colossus

Khurana HS, Groves RH Jr, Simons MP, et al. Real-time automated sampling of electronic medical records predicts hospital mortality. 

Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Johns Hopkins School of Nursing. Oncology Interdisciplinary Early Goal-Directed Sepsis Management Protocol for IPOP & HIPOP Clinic. 

Schell-Chaple H, Lee M. Reducing sepsis deaths: A systems approach to early detection and management. 

Nurses should be aware of how to identify sepsis in patients with cancer to facilitate early diagnosis and immediately treatment.

Early Sepsis Recognition in Outpatient Settings: Challenges and Progress

As nurses, we’re skilled at innovating. We have to be. The nature of our work means we often have to find new ways to help our patients. From new teach&shy;ing methods to time-saving wound care tech&shy;niques, every nurse has, at some point in his or her career, needed to think up something on the fly for the benefit of a patient.

This is innovation in action, and it's at the heart of the MakerNurse movement. Started in 2013, MakerNurse focuses on identifying and fostering nursing innovation in hospitals across the United States.

Every day, nurses and technology specialists are working to improve cancer outcomes and make both the treatment and quality of life better for oncology patients. These innovators are using technology to develop products and services that guide cancer treatment, educate patients and families, and promote well-being and a positive outlook.

While these individuals come from different educational and professional backgrounds, they are blazing a trail in the treatment of cancer. They embody the spirit of the MakerNurse movement, using creativity to develop techno&shy;logical solutions in the fight against cancer.

It’s no secret that oncol&shy;ogy care is complicated. Patients face a laby&shy;rinth of personal and financial challenges during their treatment. Treatment teams want to provide the best evi&shy;dence-based care possi&shy;ble, but are challenged by the staggering amount of available information and trouble&shy;some reimbursement systems.

Carevive Systems, a company cofounded by Carrie Stricker, PhD, RN and Madelyn Herzfeld, BSN, RN, was formed in response to the need to provide more support for patients, families, and care teams.

The idea for Carevive started in 2007 after Stricker noticed a striking need for tools to help navigate the complex world of cancer care. With over 20 years of clinical practice and nursing research experience, Stricker had repeatedly witnessed her own patients’ difficulties in nav&shy;igating through the healthcare landscape. She was inspired by the seminal Institute of Medicine 2005 report, 

to help address the reality that patients who weren't receiving active treatment were "left behind" by the system.

In response, Stricker started to develop care plans to serve people transitioning from treat&shy;ment to survivorship, but making these care plans was extremely time consuming and inef&shy;ficient. Eventually, she realized that emerging technology offered the perfect opportunity to streamline the process. In collaboration with Herzfeld, Carevive was formed in 2013 (origi&shy;nally as On Q Health) to help develop care plans for all phases of the cancer experience, based on current research and patient priorities. It’s currently being used in 30 healthcare systems across the country.

Stricker explained that Carevive’s mission is to “provide clinical workflow tools and patient engagement solutions to help cancer centers in providing comprehensive, value-based care to indi&shy;viduals and families with cancer. The goal is to sup&shy;port patients, families, and survivors in navigating their cancer experiences with optimal quality of life, and as active members of the care team.”

To that end, Carevive's cloud-based technol&shy;ogy consumes and analyzes EMR and other clinical data sources, such as tumor registry data, along with patient-reported health data, to support the care team in planning patients' treatment, managing their symptoms, and sup&shy;porting their survivorship needs. The aggregated data gathered in this process also are used to provide insight into the real-world ex&shy;periences of patients with cancer, enabling pre&shy;dictive analytics and to continuously improve outcomes.

Based on the information reported, patients receive a personalized treatment plan for managing their personal symptoms. These patient-specific plans are focused on such areas as pa&shy;tient priorities, diagnostic data, evidence-based cancer treatment pathways, possible side effects, care and outcome goals, eligibility for clinical trials, and other resources.

Clinically, providers can use the reported in&shy;formation to prioritize concerns during patient visits, encouraging better communication and collaboration between the healthcare team and the patient. The healthcare team can also use reported patient information to map out trends in symptoms, side effects, and patient outcomes. With so much of oncology care funding and reimbursement driven by census, statistics regarding patient treatment at various facilities can help drive cancer costs in a more benefi&shy;cial direction for all.

The diagnosis and treat&shy;ment of cancer might be the most emotionally devastating experience of a person’s life, but it’s not just the patient who is affected. Cancer reaches out, touching the lives of family members, friends, and even co&shy;workers. Just as an evidenced-based treatment plan is essential in the fight against cancer, so, too, is a plan for the care and support of a per&shy;son’s mental and emotional health. That’s where CanSurround comes in.

CanSurround is the brainchild of cofounders Meg Maley, BSN, RN, Jill Teixeira, MSN, RN, and John Brilliant. Both nurses had already worked in oncology for years; they collaborated together to shape an oncology home health&shy;care company, and had both consulted with WellDoc, a technology company that created software for use in a variety of medical special&shy;ties. Both women saw how the mind’s journey through the cancer experience is often—but not always&mdash;neglected.

As Maley explained, “we were very interested in the emotional ride … we wanted to pull togeth&shy;er features that were researched-based and put them on a platform whereby people could access them 24/7, confidentially and on their own terms, to help themselves manage the distress they’re feeling and move them toward resilience.”

The pilot CanSurround program launched in 2015, and the company is currently working to commercialize with cancer centers across the country. The program is available online and as a mobile app for anyone affected by cancer.

CanSurround estimates that for every 1 person diagnosed with cancer, at least 5 others are affected by the diagnosis. Patients, family, friends, and coworkers can all benefit from the program, which is focused on creating emotion&shy;al well-being and a positive, mindful approach to cancer treatment.

The program takes a personalized approach to building resilience and reducing stress by utilizing tools and resources proven to help develop a more positive mindset. This is done through education and inspiration. Users have access to a wealth of evidence-based clinical information and cancer resources, including educational materials and checklists for differ&shy;ent phases of care.

 Features also include an online journal to record positive thoughts, photos and memories, and multimedia experiences like guided imag&shy;ery, focused breathing, and meditation exercises. Through a partnership with Byron Katie, a thought inquiry program has been developed to help people identify and examine negative, stressful thoughts, one thought at a time, to promote a more positive mindset.

Another option invites users of CanSurround to join a group, allowing people to support and comfort each other in a community that understands the cancer experience intimately. Once subscribed, users will receive emails from the CanSurround team every 3 days with specially selected informational articles and messages to educate, inspire, and inform.

The idea for Sickweather was born when co&shy;founder, CEO, and president Graham Dodge became a parent. He was concerned after discovering that there was no real-time in&shy;formation about the spread of illness where he lived. During this time, another company cofounder was caring for a parent with cancer and was also worried by the lack of information about illnesses in his community.

Both men were inspired to figure out how illnesses could be tracked, so that they and the public could take more informed steps to protect against getting sick. As Dodge noted, “We see this as being something for anyone who is a caretaker for anyone else—whether its parents with young children or anybody caring for someone having chemo. It’s (for) whoever is in the position of caring for somebody else and making decisions for them.”

Although not developed specifically for pa&shy;tients with cancer, Sickweather provides invalu&shy;able information about the occurrence of illness in a person’s surrounding community. Actively avoiding areas where sickness is present is critical in oncology, because cancer and cancer treatment methods can leave a person with a severely weakened immune system.

The knowledge provided by the program can help those affected by cancer and their caregiv&shy;ers limit their exposure to illnesses that can be devastating to already fragile patients.

Sickweather is available online or as a mo&shy;bile app. The program uses preset algorithms to scan social media networks like Facebook and Twitter for illness by using keywords. Data are also collected from crowdsourced inputs.

 Currently, the app is tracking reports in En&shy;glish only, but includes all regions around the world where English is the primary language. Once the resources are available, the company hopes to start translating reports from other languages.

When an illness has been identified, the information about the location of the report is entered into a database, which then shows that information on a map—down to street level and in real time. Individuals can also enter illness information into the system independently. The program collects about 6 million separate re&shy;ports every month.

Users can see where sickness outbreaks were occurring and when they are occurring. People

also can receive illness alerts if they subscribe to Sickweather, making it possible for them to consciously avoid those areas where illness is occurring.

These are just three examples of innovation in action—inspired by healthcare providers and technology professionals working together to create new software products that benefit oncol&shy;ogy patients and others. With these tools, it is now possible to reach more patients and health&shy;care providers. The spirit of the MakerNurse movement is at the heart of each of these inno&shy;vations, making the journey though the cancer experience more positive and less stressful.

 A community of inventive nurses creating solutions to improve patient care every day, providing tools, platforms, and training to help MakerNurses create the next genera&shy;tion of health technology.

 Provides a range of tools to support oncology practitioners in their efforts to improve patient care and outcomes, including Electronic Patient-Reported Outcomes (e-PRO), Clinical Trial Accrual, Initial Treatment Plans, Dis&shy;tress/Symptom Management Plans, and Survivorship Care Plans.

 Focuses on reducing stress, building resil&shy;ience, and enhancing well-being for individ&shy;uals affected by cancer, with such features as a multimedia journal, mind—body exercises, and a circle of support, all with an eye toward providing individuals with a healing space accessible anytime, anywhere. For a limited time, patients and caregivers are invited to sign up at CanSurround as early partici&shy;pants, free of charge.

 This sickness forecasting and mapping tool can be especially useful to patients with compromised immune systems due to cancer or its treatment, alerting them to the risk of contagious illness in their area. The program is free; anyone can join, anytime, to start tracking illnesses in their area.

Sarah Handzel, BSN, RN

Articles

Zero Tolerance: Stopping Nurse Bullying Begins With Leadership

Early Sepsis Recognition in Outpatient Settings: Challenges and Progress

Nurse-Designed Software Innovations Are Changing the Cancer Experience