Workplace Civility and the Caring Theory at JCLNMH

1. Workplace Civility and the Caring Theory at JCLNMH Sandy Thompson RN-BC, MS Arizona Nurses Association Greater Phoenix Area Chapter 1 May 14, 2008

2. Question: Which of these scenarios are considered “Workplace Incivility”? • Rolling eyes or making a face when another nurse is speaking • Significant information withheld regarding a patient/ family during shift report • Uneven distribution of work in nurse assignments • Nurses refusing to help co-workers who are busy • Talking about a nurse after he/ she has left the break room

3. Answer: • ALL OF THEM!

4. Workplace Civility • Definition: • Civility is behavior that shows respect for another, causes another to feel valued, and contributes to mutual respect, effective communication, and team collaboration; can be verbal, nonverbal, or behavioral Center for American Nurses, 2007

5. Workplace Incivility • Definition: • The opposite of civility • Can be observed as: • Verbal abuse • Physical or sexual abuse • Negative behavior • Often referred to as: • Horizontal violence • Lateral violence • Bullying behavior Center for American Nurses, 2007

6. Verbal Abuse • Profanity, demeaning comments, intimidating language, yelling, devaluing, discouraging, condescending language or voice intonation, impatience with questions or phone calls • Being reprimanded in front of others, insulting another’s knowledge in front of patient/family, threat, racial or ethnic jokes, criticizing others in public, argumentative behavior

7. Physical or Sexual Abuse • Physical: • Assault and battery • Throwing objects (instruments or charts) • Outbursts of rage or violence (slamming things or hitting the wall) • Sexual • Inappropriate touching or language • Inappropriate jokes of a sexual nature

8. Workplace Bullying • Repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators that takes one or more of the following forms: verbal abuse; threatening, humiliating or offensive behavior/ actions; work interference—sabotage—which prevents work from getting done. Center for American Nurses, 2007

9. Negative or Disruptive Behavior • Disruptive behavior • Behavior that interferes with effective communication among healthcare providers and negatively impacts performance and outcomes; behavior is not supportive of a culture of safety • Examples: • Scape-goating, backstabbing, complaining, perpetuating rumors • Behavior whose purpose is to control, humiliate, denigrate or injure the dignity of oppressed colleagues • Being expected to do another’s work (clean up after them) • Behaviors which undermine team cohesion, staff morale, self worth and safety; withholding information • Unethical or dishonest behavior, ineffective, nonproductive forms of conflict resolution, cultural bias Center for American Nurses, 2007

10. Where does it come from? • Physicians • Patients • Visitors • Other disciplines • Nursing colleagues Center for American Nurses, 2007

11. Why does it occur? • Culture • “Handmaiden” • Female dominated profession • Oppressed culture mentality • Lack of administrative support • Acceptance as the “norm” • “Reality shock” • “Nurses eat their young” Center for American Nurses, 2007

12. When does it occur? • Questioning physician’s order • Difference of opinion in patient’s care • Family or patient perceptions of care, treatment, or outcomes • Daily interactions among nursing staff and/or between nurses and other departments Center for American Nurses, 2007

13. What are the effects? • Decreased self-esteem & morale • Decreased nurse satisfaction • Increased turnover • Decreased patient safety (errors) • Decreased patient satisfaction • Diminished Image of Nursing • Other departments • Other nurses • Our customers Farrell, 2001

14. Most Frequent Forms of Lateral Violence in the Workplace • Nonverbal innuendo (raising eyebrows, face-making) • Verbal affront (covert or overt, snide remarks, lack of openness, abrupt responses) • Undermining activities (turning away, not available) • Withholding information (practice or patient) As cited in Griffin, 2004

15. Most Frequent Forms of Lateral Violence in the Workplace • Sabotage (deliberately setting up a negative situation) • Infighting (bickering with peers) • Scapegoating (attributing all that goes wrong to one individual) • Backstabbing (complaining to others about an individual and not speaking directly to the individual) • Failure to respect privacy • Broken confidences As cited in Griffin, 2004

16. What can we do? • Education • Identification of offensive behaviors • Communication techniques • Personal accountability • Self-monitoring • Support each other • Professional accountability • JCL policy re: harassment • Support healthcare professionals

17. Recommendations from the Center for American Nurses • Nurses • Learn to recognize and appropriately address bullying and disruptive behavior in the workplace • Enhance their knowledge base and skill set related to conflict management and effective conflict resolution • Participate in collaborative interdisciplinary initiatives to prevent abuse • Work to influence policies, standards, values, and the culture of their workplace to reflect the Code of Ethics for Nurses in order to eliminate lateral violence and disruptive behavior Center for American Nurses, 2007

18. Recommendations from the Center for American Nurses • Employers • Implement effective zero tolerance policies in the workplace regarding bullying and violence • Promote a Culture of Safety that encourages open and respectful communication among all healthcare providers and staff • Provide support to those who have been bullied • Provide education and counseling to victims and the perpetrators of horizontal violence and bullying Center for American Nurses, 2007

19. Recommendations from the Center for American Nurses • Nursing Continuing & Academic Programs • Disseminate information to nurses and students that address conflict and provide information about how to change abusive behavior in the workplace • Address bullying and disruptive behavior; these programs need to include the incidence and consequences of such behaviors in the workplace, as well as provide strategies to address such behaviors • Develop and implement curricula that educate nursing students on the incidence of workplace violence, along with steps to take to eradicate it Center for American Nurses, 2007

20. Recommendations from the Center for American Nurses • Nursing Research • Continue to research lateral violence and disruptive behavior to further the understanding of the contributors and process of abusive as well as counterproductive behaviors • Build on previous and current studies while seeking to explore innovative ideas on how to eliminate manifestations of violence • Evaluate the efficacy of promising strategies in eliminating abuse and violence from the workplace Center for American Nurses, 2007

21. What does this mean to me? • Increased awareness (education) • Hold ourselves accountable (self-reflection) • Hold others accountable (professional accountability) • Support one another (professional accountability)

22. Personal Accountability • What are we saying to others? • How are we saying it? • What non-verbal cues am I conveying? • Would I like to be spoken to/ treated in this manner? • Practice sef-reflection

23. Personal Accountability • Accept one’s fair share of the workload • Respect the privacy of others • Be cooperative with regard to the shared physical working conditions • Be willing to help when requested • Keep confidences • Work cooperatively despite feelings of dislike • Don’t denigrate to superiors (ex. Speak negatively about, have a pet name for) Griffin, 2004

24. Personal Accountability • Do address co-workers by their first name, ask for help and advice when necessary • Look co-workers in the eye when having a conversation • Don’t be too overly inquisitive about each others’ lives • Repay debts, favors, and compliments, no matter how small Griffin, 2004

25. Personal Accountability • Don’t engage in conversation about a co-worker with another co-worker • Stand up for the “absent member” in a conversation when he or she is not present • Don’t criticize publicly Griffin, 2004

26. Professional Accountability • Be aware of when workplace incivility or bullying is occurring • Be prepared to intervene immediately, even when despite your discomfort • Utilize cognitive rehearsal • A method of confronting the situation without being confrontational

27. Cognitive Rehearsal • Provides a “shield” or mechanism of defense against lateral violence Mental plans that individuals can use to understand themselves and their environment • Behavior and responses to events can be changed through techniques in which persons learn specific responses • Hold in the mind information just received • Consciously decide not to respond or react • Gives time to process information received and not automatically consider as a personal affront • Respond differently to the potentially harmful information or behavior based on rehearsed scripting Griffin, 2004

28. Cognitive Rehearsal • Nonverbal Innuendo • Try to draw out more information • “I sense that you want to say something to me. It’s okay to speak directly to me.” • Verbal Affront • Calmly confront the situation • “The individuals I learn the most from are clearer in their directions and feedback. Is there some way we can create this type of situation?” Griffin, 2004

29. Cognitive Rehearsal • Undermining Activities • Seek clarification • “When something happens that is different or contrary to what I understand, it leaves me with questions. Help me understand how this situation may have happened.” • Withholding Information • Seek information • “It is my understanding that there is/was more information available regarding this situation, and I believe if I had known that (more), it would/will affect how I learn or need to know.” Griffin, 2004

30. Cognitive Rehearsal • Sabotage • Privately strategize • “There is more to this situation than meets the eye. Could you and I meet in private and explore what happened?” • Infighting • Avoid as this is extremely unprofessional • “This is not the time or the place. Please stop.” (Physically walk away or move to a neutral spot.) Griffin, 2004

31. Cognitive Rehearsal • Scapegoating • Recognize that rarely is one individual, one incident, or one situation the cause for all that goes wrong. • “I don’t think that’s the right connection.” • Backstabbing • Represent the absent person • “I don’t feel right talking about him/her/situation when I wasn’t there or don’t know the facts. Have you spoken directly to him/her?” Griffin, 2004

32. Cognitive Rehearsal • Failure to Respect Privacy • Practice discretion • “It bothers me to talk about that without his/her/their permission.” • Broken Confidences • Advocate for the injured party • “That sounds information that should remain confidential.” Griffin, 2004

33. Professional Accountability • Support each other • Recognize an “assault” when it occurs • Debrief as necessary • Reinforce the appropriate use of cognitive scripting • Demonstrating caring behavior for each other • Discuss with management as appropriate

34. Resources • Arizona Nurses Association • http://www.aznurse.org • Center for American Nurses • http://centerforamericannurses.org

35. References • Cardillo, D. (2008). Foster horizontal respect. Nurseweek Southwest Edition, 9(5), 46-47. • Center for American Nurses (2007, August). Lateral/ horizontal violence and bullying in the workplace [Draft for Board Approval]. Retrieved from http://www.centerforamericannurses.org/positions/violence07.htm • Farrell, G. (2001). From tall poppies to squashed weeds: Why don’t nurses pull together more? Journal of Advanced Nursing, 35(1), 26-33. • Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of Continuing Education in Nursing, 35(6), 257-263.