unProfessionalism in Nursing CE Course

ysiology and pharmacology, and critical nursing skills. Given the sheer volume of information nurses need to learn, professional behaviors are often not a priority. 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 (2025). The Code lists 10 provisions that nurses can use to help make decisions and guide their conduct as professionals (ANA, 2025).

• Nurses practice with compassion and respect for every person's inherent dignity, worth, and unique attributes of every person without prejudice. This includes an expectation of respectful interactions and conflict resolution with colleagues and compassion and respect for the uniqueness of patients. (Provision 1)
• Nurses’ primary commitment is to the recipient(s) of nursing care, whether an individual, family, group, community, or population. (Provision 2)
• Nurses establish a trusting relationship and advocate for the rights, health, and safety of recipient(s) of nursing care. (Provision 3)
• Nurses have authority over nursing practice and are responsible and accountable for their practice, which is consistent with their obligations to promote health, prevent illness, and provide optimal care. (Provision 4) Accountability includes expecting nurses to accept responsibility for assessing their competence and then seeking help, guidance, and further training or education when the current level of competence is lacking.
• Nurses have moral duties to self as a person of Inherent dignity and worth, including an expectation of a safe place to work that fosters flourishing, authenticity of self at work, and self-respect through Integrity and professional competence. (Provision 5) This includes basic needs such as ensuring adequate nutrition and sleep, and maintaining emotional and spiritual well-being as defined by the nurses.
• Nurses, through individual and collective effort, establish, maintain, and improve the ethical environment of the work setting that affects nursing care and the well-being of nurses. (Provision 6)
• Nurses advance the profession through multiple approaches to knowledge development, professional standards, and the generation of policies for nursing, health, and social concerns. (Provision 7) Nurses collaborate with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
• Nurses build collaborative relationships and networks with nurses, other health care and non-health care disciplines, and the public to achieve greater ends. (Provision 8)
• Nurses and their professional organizations work to enact and resource practices, policies, and legislation to promote social justice, eliminate health inequities, and facilitate human flourishing. (Provision 9)
• Nursing, through organizations and associations, participates in the global nursing and health community to promote human and environmental health, well-being, and flourishing. (Provision 10)

Professional organizations, certifying bodies, health care 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, n.d., section b).

Ethical Behavior

The ANA's revised Code has specific provisions that apply to the professional conduct of nurses. Provision 6 is often interpreted as nurses' responsibility to help create and maintain a safe and ethical work environment for themselves (ANA, 2025). Ethical practice is tied to standard 7 of the ANA's Scope and Standards of Practice (ANA, n.d.-b). Ethical principles that guide health care delivery by nurses can also help shape what should define professionalism. Basic ethical principles for nurses include:

• Autonomy and the right to use self-determination to 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 respect 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.
• Trustworthiness and integrity are principles that encourage 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 (Varkey, 2021).

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) (ANA, 2024; Robichaux & Vittone, 2023). 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. Guidelines from the International Council of Nursing's (ICN) Code of Ethics for Nurses and the ANA help nurses navigate these difficult ethical decisions. 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 (Grace et al., 2024).

If nurses can check all these boxes, they have a moral obligation to the patient to provide the expected care (Grace et al., 2024).

 

Self-Care

As Provision 5 of the ANA Code (2025) states, 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 (Williams et al., 2022). However, in light of the challenging 12-hr shifts and the 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 with consequences that can be catastrophic; decreased functional or short-term memory ability; reduced learning ability; poor decision-making; decreased reaction times, attention, and vigilance; increased risk-taking behaviors; poor mood; reduced communication; and numerous physical health consequences (Steven & Redfern, 2024). 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 (Steven & Redfern, 2024; Williams et al., 2022). Therefore, the ANA recommends that healthcare providers (HCPs), including nurses, limit their working hours to 12 in 24 hr and no more than 40 hr in 7 days. Working over 40 hr in a week has been shown to affect patient safety and HCP health. The ANA also includes several other suggestions to minimize nurse fatigue and optimize performance, such as:

• Arrive for work alert and well-rested.
• Sleep at least 7 to 9 hours in 24 hr.
• Rest before the beginning of a shift.
• Avoid caffeinated beverages prior to sleep and 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.
• Optimize general health by managing stress, maintaining good nutrition, and exercising regularly.
• Ask the manager or supervisor for a copy of the institution's nap policy, as many hospitals have a specific policy to address this issue (Occupational Safety and Health Administration [OSHA], n.d.-a; Sprajcer et al., 2023).

Nurses not taking break periods during their shifts have also become a professional norm, especially in acute care. A generally acceptable goal for a nurse is to take three 15-min breaks and one meal break (typically 30 min) in a 12-hr 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. Recent reports reveal that 1 in 3 nurses never or rarely take a meal break, and 1 in 10 do not take a break of proper length. While this goal may seem difficult to achieve, adequate breaks are integral to nursing job satisfaction and safety (Allan, 2022). Some states have enacted laws surrounding break periods for HCPs working in hospitals to help empower nurses to use 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 hr between shifts. The bill also eliminates mandatory overtime shifts and outlines limitations to on-call shifts used to circumvent mandatory overtime regulations (Washington State Legislature, n.d.; Washington State Nurses Association, 2021).

 

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 (National Council of State Boards of Nursing [NCSBN], n.d.). Provision 4 of the ANA Code 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, nurses are ultimately responsible for speaking up and seeking out any additional information that was potentially overlooked. Provision 5 includes the expectation for continued growth and professional development throughout a nurse's career (ANA, 2025). 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. 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. Cost can be a barrier, but the benefits significantly surpass the cost (Ko, 2022). The expectation that nurses become lifelong learners and maintain knowledge and competence in current nursing practice is reiterated in standard 13 of the ANA's Scope and Standards of Practice (ANA, n.d.-b).

 

Communication

The ANA Code (2025) plainly states that patients are nurses’ primary responsibility, so many professional behaviors are directly related to patient safety. As health care 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 use 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 by leading by example (ANA, 2023a; Robichaux & Vittone, 2023).

When communicating, 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. Next, care should be implemented and communicated according to the care plan (step 4), ensuring continuity of care for the patient from hospitalization to discharge and the resumption of outpatient services. Establishing a care plan, communicating the plan, and following through is 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.-c).

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 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-hr 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 in 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 nurses the opportunity to gain knowledge and build new skills. While nurses have 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 floating nurses to 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 (Registered Nurse Safe Staffing Act of 2015, 2015). 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 (Bitanga, n.d.)

Finally, as floating nurses, there should be support and encouragement for honest and open feedback, without fear of retribution or judgment, at the end of the shift regarding what went well and what could have been made easier with specific and constructive suggestions (Bitanga, n.d.; Ghonem & El-Husany, 2023).

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, health care 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 competently completed a skill 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 health care, 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 at 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, n.d.)

Consequences of Unprofessional Behavior

Unprofessional behavior in the workplace, including health care settings, can have far-reaching consequences. Unprofessional behavior can decrease 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 develop physical manifestations or feel isolated, uncertain, depressed, angry, or fearful while working. This may affect their ability to think clearly, make critical judgments, and voice concerns, ultimately impacting patient care and outcomes (Dabekaussen et al., 2023; Shoorideh et al., 2021).

 

Errors

While errors are a normal part of human existence, for nurses, some errors can be deadly for the patient. According to Rodziewicz and colleagues (2024), medical errors are the third most common cause of death in the United States, with over 200,000 deaths occurring annually due to preventable medical errors. A key element in patient safety involves fostering a safe, fair, blame-free environment of interdisciplinary teamwork (Dabekaussen et al., 2023). 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 specialty units such as intensive care units (ICUs) and operating rooms (ORs). Errors can be prevented by implementing safeguards and setting up workflows to limit mistakes. Some of the most common and most dangerous nursing errors and how to avoid them include (Atanasov et al., 2020; Rodziewicz et al., 2024):

• Medication errors include not diluting a medication before administration, administering medication via the wrong route, giving the wrong dose, or mixing incompatible medications. Nurses should avoid distractions during medication administration and use the "8 rights" (right patient, right time, right drug, right dose, right route, right reason, right documentation, and right response). Nurses should not hesitate to ask questions or double-check something, especially if it looks different or incorrect. Most of these errors are often related to medication (Hanson & Haddad, 2023; Rodziewicz et al., 2024; Singh et al., 2024).
• 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 using a fall risk assessment (e.g., Morse fall scale), 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 for nurses to limit the risk and spread of hospital-acquired infections, in combination with sterilizing equipment and good aseptic technique (Centers for Disease Control and Prevention [CDC], 2024).
• Documentation errors include incorrect abbreviations, charting under the wrong patient, and dictation and transcription errors. The adage in health care also rings true today: If you did not document it, it did not happen. Nurses should document all interventions along with the time they were completed. The same principle applies to interventions that were not completed. Nurses should document why a particular intervention was not carried out as ordered (e.g., the patient refused a medication) (Ghaith et al., 2022).
• 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., gait belt), 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 (Fray & Davis, 2024; OSHA, n.d.-b).
• 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 (Fray & Davis, 2024).
• 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 (ANA, 2023b; Rodziewicz et al., 2024).

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 has four essential elements that must be present: causation, duty, negligence or breach of duty, and damages (Bono et al., 2022; Ghaith et al., 2022).

In addition to having grave consequences for the patient, errors can also lead to malpractice and other legal issues for nurses. Common reasons 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 (Faubion, n.d.-a).

                

Disruptive Behavior 

Unfortunately, disruptive behavior is common in health care, 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). Unprofessional or disruptive behavior is defined as "any interpersonal behavior by staff that causes distress or harm to other staff in the health care workplace" (Aunger et al., 2023, article number 1326). 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 respondents had witnessed disruptive behavior most often by nurses. This behavior increases the risk of medical errors, adverse events, and deaths (Dabekaussen et al., 2023). In addition, disruptive behavior is a known cause of decreased job satisfaction, worsened personal health, additional health care costs, and overall decreased patient safety (Aunger et al., 2023). TJC's code of conduct instructs health care 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 (Maben et al., 2023). Among nurses, incivility manifests as rudeness, wrongful blaming, ignoring, interrupting, yelling, taking credit for someone else's work, gossiping, or refusing to assist coworkers (Freedman et al., 2024). The ANA places the responsibility on nurses to treat colleagues, coworkers, employees, employers, students, and others with respect and dignity(ANA, 2025).

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. There are four main classifications of violence in the workplace: Type I (with criminal intent), Type II (with patients, clients, families), Type III (with worker-on-worker), and Type IV (with interpersonal relationships), with Types II and III occurring most often in health care settings (Al-Qadi, 2021; The National Institute for Occupational Safety and Health [NIOSH], 2022). Workers in the U.S. health care settings experienced 73% of all workplace injuries not resulting in death, at least three times that of other industries. Alarmingly, the Bureau of Labor Statistics (BLS) reports that health care workers experience workplace violence 16 times more than other types of workers (Travaini et al., 2024). The highest rates of physical violence have been reported in emergency departments, home health, and psychiatric facilities (Lombardi et al., 2024). Multiple studies found that the rates of Type II violence against nurses increased during the COVID-19 pandemic, in both physical and non-physical violence (44% and 68%, respectively) (Byon et al., 2022).

When nurses exhibit these behaviors against each other, it is known as Type III worker-on-worker violence. This lateral or horizontal violence and the negative interactions it leads to between nurses are well-known and have been extensively researched and reported. Lateral or horizontal violence can have significant consequences for nurses in their work environment and personal lives. In a literature review of 13 studies on horizontal violence in health care, 79.4% of health care workers reported experiencing Type III lateral or horizontal violence (Travaini et al., 2024).  In a meta-analysis of 47 observational studies, it was found that verbal abuse (61.2%) occurs most frequently, followed by psychological violence (50.8%) and threats (39.5%), with physical violence (13.7%) and sexual harassment (6.3%) occurring less often (Lim et al., 2022).

Lateral or horizontal violence is most commonly non-physical violence manifesting as psychological harassment. Behaviors of harassment include threats, insulting, patronizing, ignoring, intimidation, body shaming, and use of sexual innuendos. These behaviors can manifest as withholding vital information, denying assistance, belittling, yelling, and being left or set up to fail (Travaini et al., 2024). 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 not repeated. Bullying is an enduring behavior that is repeated with the intent to offend, harm, humiliate, degrade, or undermine. This can include verbal attacks, taunting, intimidation, threats, unsupportiveness, or hostile remarks (NIOSH, 2022). The literature has shown that lateral violence in the workplace leads to decreased patient safety and worker disengagement, retaliation, absenteeism, poor job satisfaction, and high turnover rates. There is also evidence that individuals experience decreased self-confidence, emotional exhaustion, and poor physical and mental health resulting from incivility and bullying (Travaini et al., 2024).

The other type of workplace harassment is sexual harassment. Sexual harassment is defined by the US 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 refer to the Nursing CE course on Sexual Harassment Prevention for more information on this topic.

 

Absenteeism 

Absenteeism and tardiness are unprofessional behaviors that 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 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 assume a 10% to 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, n.d.; Mitra et al., 2024).

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 endangering 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. A short leave of absence to attend a family member's funeral is reasonable and expected, especially for immediate family members. However, unexpected absences for transportation and childcare issues can often be avoided by ensuring reliable forms of both and considering contingency or backup plans in advance. Avoiding double shifts and other forms of overtime has also decreased absenteeism (MasterStreet, n.d.; Mitra et al., 2024).

 

Retention 

Unprofessional behavior decreases employee satisfaction, leading to high staff turnover rates. According to Alexis and colleagues (2020), retaining staff saves health care institutions money on recruitment, orientation, and supplemental staffing. Lockhart (2020) explains that 18% of new nurses change jobs or leave the nursing profession within 1 year of graduation. Over 2 years, that rate increased to 33%. The 2024 NSI National Health Care Retention and RN Staffing Report states that the nursing turnover rate is currently 18.4%, a decrease of just over 4.0% from 2022. The cost to replace a bedside RN ranges from $45,100 to $67,500, and averages $56,300. Turnover of nursing staff can cost an institution up to $5.79 million every year. Despite all this money spent on recruiting and training, 30.2% of new hires leave their position within the first year, and 62.2% leave within the first 2 years (NSI Nursing Solutions, 2024).

Nurses report a variety of reasons for leaving their current position, including relocation, career advancement, personal reasons, retirement, education, working conditions, salary, commute, staffing/workload ratios, and scheduling. During the COVID-19 pandemic, the turnover rate of RNs significantly increased to 27.1%. It has declined since then, with a rate of 18.4% in 2023. 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 stepdown (22.2%), telemetry units (23.7%), and emergency medicine (22.4%). This equates to each department replacing its nursing staff every 4 to 5 years. By contrast, pediatrics (13.3%) and surgical services (15.4%) have the lowest turnover rates (NSI Nursing Solutions, 2024).

The current national vacancy rate of nursing positions has decreased by 5.8% between 2022 and 2023 but remains elevated at 9.9%, with 47.8% of hospitals reporting a vacancy rate of over 10%. During the COVID-19 pandemic, the cost of agency nurses skyrocketed, with rates increasing weekly. Currently, hospitals indicate a significant desire (80%) to decrease spending on travel nurses. It is estimated that for every 20 travel nurses used to fill vacancies, the cost to the hospital exceeds 2 million dollars. Agency staff are often used temporarily to fill vacancies. Depending on the specialty, it takes 80 to 109 days to recruit a new nurse. These numbers have recently started to level off since 2020. For example, it took 96 days to recruit a critical care nurse in 2022; in 2023, it took 94 days to recruit for that same position (NSI Nursing Solutions, 2024).

There are things that health care 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 shifts 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).

 

Underrepresented or Marginalized Populations

                As the workforce diversifies, women and individuals from underrepresented groups (based on gender identity, sexual orientation, race, and ethnicity) may find themselves subject to noninclusive 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, noninclusive 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 from underrepresented or marginalized groups may experience unprofessionalism differently than others. 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. Professional standards are also applied differently to those who 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 female individuals, 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 Ofei and colleagues (2023), the following signs may identify a "toxic culture" or unhealthy work environment.

• 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) (Freedman et al., 2024; Ofei et al., 2023)

So, what if nurses find themselves in an unacceptable position despite their best efforts? Is it simply time to move on to the next great adventure? Giving notice of resignation should be done professionally. Giving ample notice shows respect to the manager, coworkers, and patients. While 2 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 use 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 4 weeks. The decision to resign 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 their last day. Human Resources often conducts anonymous exit interviews to allow an additional opportunity for constructive and transparent feedback (Nogrady, 2022). The most recent 2023 Gallup poll found that 78% of the American public rated nurses as the most honest and ethical profession, down 11 points from the peak in 2020 (Brennan & Jones, 2024). Let's ensure that nurses strive to maintain and honor trust daily.

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