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Tell Me Your Story…
Healing Nurse to Nurse Hostility and
Creating Healthy Relationships
Kathleen Bartholomew, RN, MN
“Alas, culture is not what we say, what we think, what we mean, or
even what we intend;
it's what we do.”
Jon Burroughs, MD
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Human Adaptability
Changes that are small and incremental are not noticed
Horizontal Hostility
A consistent (hidden) pattern of behavior designed to control, diminish,
or devalue another peer (or group) that creates a risk to health
and/or safety
(Quine 1999, Farrell 2005)
Shares 3 elements common to racial and sexual harassments laws:
1. Defined in terms of effect on recipient2. Must be a negative effect on victim3. The bullying behavior must be consistent
(Quine, 1999)
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Overt:name-calling, sarcasm, bickering, fault-finding, back-stabbing, criticism, intimidation, gossip, shouting, blaming, put-downs, raising eyebrows, etc.
Covert:unfair assignments, eye-rolling, ignoring, making faces (behind someone’s back), refusal to help, sighing, whining, sarcasm, refusal to work with someone, sabotage, isolation, exclusion, fabrication, etc.
United States
Empirical studies
1. 82% witnessed in last yr.2. 77% saw negative RN-RN behaviors2. 28% in survey of US occupations 2. 31% Mass. Study 3. 27.3% bullied in last 6 mo. 4. 46% reported serious LV behaviors
Verbal abuse from physicians 90-97% ?
United States
Verbal abuse from physicians 90-97%
Verbal abuse cited as reason nurses leave
60% of newly registered nurses leave their first position within 6 mo. because of some form of lateral violence
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“Of all types of aggressionnurses experience, peer to peer hostility is the most harmful.”
Farrell, 1999
Individual Impact
- Psychological, physical, emotional and social- Nurses who report highest degree of conflict
also report the highest degree of burnout- Decreased job satisfaction and morale,
- Increased intent to leave
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Theoretical Framework
•Oppression Theory–Major characteristics of oppressed behavior stem from the ability of dominant groups to identify the “right” norms and values and from their power to enforce them.
Dominant Group
Oppressed Group
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OBJECTIVE
SUBJECTIVE
SCIENCE
ART
CURE
CARE
LEFT BRAIN
RIGHT BRAIN
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When what you do is disconnected from what you value,
You begin to feel anger, fear, helplessness and a lack of energy
(Quine 1996)
Whose doing the bullying?
• 50% identified managers/directors
• 25% identified charge nurses
• 29 % physicians
• 38% coworkers
JONA Vol. 39(2)
New Grads
• 60% of newly registered nurses leave their first position within 6 mo. because of some form of lateral violence Griffin
• Almost half of new grads experienced
humiliation and rudeness; and distress
McKenna
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Life Classic Photographs by J. Loengard
Life Classic Photographs by J. Loengard
The Current Situation
• Our lifestyles, our choices…– 23.7% married with kids– children sicker than parents– 5 million> relocating a year– decreased time for self/community – 60+ hr. work week/longer commute– the pace of our lives
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Emotions running strong…
Because nurses
– do not have an outlet for frustration– do not have an opportunity to
process (reflection)– are wounded by horizontal hostility– lack a support system/solidarity– have adapted to an increased pace of
work and workload
Intrinsic Factors
• Emotional State – anger, burnout• Personality Style – Type “A”• Intermittent reinforcement is strongest• Inadequate communication and
conflict management skills • Beliefs and expectations• Culture of little-no feedback
Extrinsic Factors
• Violent workplace • Poor nurse-physician relationships• Task and time imperatives• Changing role/responsibilities of managers• Demands for efficiency/productivity
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Aftermath…
• “Nearly everyone got even”
• Intentionally lower productivity
• Cut back hours
• Give minimal effort
• Left the job – months afterward
• Lost respect for boss(The Cost of Bad Behavior)
Impact
- Recruitment/ Retention in a shortage
- Lack of staff due to increased sick days
related to stress and burnout
- Creates a toxic work environment
- Failure to achieve solidarity
- Patient safety – can’t think clearly when upset
Summary
• History of powerlessness• Lack of time for reflection• Decreased social capital• Human Adaptability
The work is compressed and complex – we
have adapted to an increased pace
• Inadequate confrontation skills
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“The future …materializes from the actions, values and beliefs we’re practicing now.
We are creating the future every day by what we choose to do…
…If we want a different future
we have to take responsibility for what we are doing
in the present.”
Wheatley 2002
The Bully-Busting BillBill 168
• Amendment to OSHA - June 15, 2010
• Ensures that workers will now be protected from violence and harassment through policy and procedure
• “Statements or behaviour that is reasonable for a worker to interpret as a threat…”
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“Our lives begin to end the day we become silent about things that matter”
M. L. King
Why don’t you speak your truth?
• Fear of retaliation
• Fear of hurting the relationship/feelings
• Fear of gossip, scapegoating,
• No time
• Why bother? Nothing will change
• Fear of being isolated from the group
(Bartholomew, 09)
www.silencekills.com
• 84% of MD’s have seen coworkers taking shortcuts that could be dangerous to patients
• 88% of MD’s say they work with people who show poor clinical judgment
• Fewer than 10% of MD’s, RN’s and clinical staff directly confront their colleagues about concerns
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2012 Hospital Survey on Patient Safety Culture
• 37% will not report a potential error as it is happening
• Nearly half of 600,000 staffers said they believe their mistakes are held against them
• 54% said "it feels like the person is being written up, not the problem”
Sorra J, Famolaro T, Dyer N, et al. Hospital Survey on Patient Safety Culture 2012 user comparative database report
www.silencekills.com
• 78% said it was difficult if impossible to confront a person or group directly (keeping silent) if they exhibited incompetent care
• “Self Silencing” (Jack 1991)
• “Value relationship so much that they will sacrifice interpersonal confrontation and assertiveness to keep the peace”
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DESC Communication Model
• Describe - Lead with the facts• Explain – Let them know the impact
(pause, pause, pause)
• State – What you want. Be descriptive• Consequences – Describe the impact
(individual, social and work env)
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What do you say after you hear that someone has been backstabbing you?
D
E
S
C
DESC Communication Model
D - When…
E - I feel…because
S - Therefore, I want (I need)
C - So that…
How do I approach an experienced nurse when she makes it obvious in many ways that she has no time patience or empathy for my concerns?
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D – I noticed today you felt bothered by my questions and I felt in the way
E - I understand your workload is heavy, but when you ignore me, I feel unimportant and get the message that you wish I wasn’t here
S - I need to find some way or some time to connect with you. I really want to learn and be the best nurse I can be.
C - If you continue to ignore me, I can’t learn and I won’t stay
Professional Behaviors
• Accept one’s fair share of the workload• Keep confidences• Work cooperatively, despite feelings of dislike• Always look co-workers in the eye• Don’t engage in conversation about a coworker• Stand up for an “absent member” in conversations• Don’t criticize publicly• Don’t be overly inquisitive about each other’s lives• Do repay debts, favors, and compliments
Responding to to
Hostility
Non-verbal inuendos (e.g. making faces)
“I see from your facial expression that there may be something you wanted to say to me. It’s ok to speak to me directly”
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Sabotage (setting up a negative situation)
“There is more to this situation than meets the eye. Could you and I (or whoever) meet in private and explore what happened?”
Verbal affront (covert or overt snide remarks, lack of openness or abrupt responses)
“Can I talk to you in private? When you____ I got the feeling that you______. Is that the case?”
Undermining (turning away or being unavailable)
“Can you help me understand how this situation could have happened?”
Withholding information (practice or patient)
“It is my understanding that there was more information available regarding the situation, and if I had known that, it would have affected what I did “
M. Griffin
Infighting (bickering with peers)“This is not the time or place. Please stop” Then
physically walk away or move to a neutral spot
Backstabbing (complaining to others about an individual)
“I don’t feel right talking about him/her/the situation when I wasn’t there. Have you spoken to him/her? “
M. Griffin
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Action Plan for New Staff
1. Preceptor Feedback2. Increase One-on-One Time
- share a meal the first month- decrease the preceptor’s workload
3. Encourage compliments4. Make time for reflective practice5. Review professional behaviors 6. Differentiate new staff <1 yr. with nametag7. Ask senior staff to share their experiences
Response: Strategies and Tools
1. Decrease negativity, gossip and a culture of blameby maintaining a zero tolerance for any communication that is unhealthy
2. Increase a climate of safety and healthy communication by role modeling and utilizing opportunities to teach interpersonal and confrontationskills.
To thrive horizontal hostility needs:
secrecyshamesilent witness *
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The Grey Zone
Any intervention that…
1. Flattens the hierarchical structure2. Empowers staff, increases “voice”3. Builds self esteem4. Raises awareness of the problem5. Provides opportunities for networking6. Supports reflective practice7. Illuminates the problem by showing the
consequences
…will decrease horizontal hostility
What can you do?
1. Ask for Feedback - todayWhat do I do well?What would you like to see more of?
2. Always speak your truthSelf silencing = powerlessness
3. Call it what it is…Make the non-verbal, verbal
4. NEVER be a “silent witness”“Nothing About Me Without Me”
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Thank you!
• Kathleen Bartholomew
• 206-356-2599
• www.kathleenbartholomew.com
