“No Bullying Zone”: Cultivating a Fair and Just Nursing Culture

Presented by: Patrice L. Brown, BSN RN

Clinical Nurse, Emory Healthcare

NBNA's 44th Annual Institute and Conference -"Nursing: Advancing Healthcare Practices through Diversity and Collaboration“

Violence Prevention Institute

Objectives

1. Demonstrate basic knowledge of ethical and legal ramifications associated with bullying in the nursing profession

2. Recognize physical, psychological, and occupational effects of bullying

3. Discuss the use of role playing and open communication in conflict resolution

Disclosures

• Patrice Brown is employed as a Registered Nurse with Emory Healthcare. She has no relevant financial relationships to disclose.

Disclaimer

• No part of this presentation is to be construed as legal advice. If legal advice is required, the services of a competent lawyer should be sought.

Factoids • Emory Healthcare is the largest healthcare system in

the state of Georgia., United States. 6

• Emory Healthcare is a multidisciplinary academic medical organization comprising seven hospitals, the Emory Clinic and more than 200 provider locations. 6

• The Emory Healthcare Network, established in 2011, is the largest clinically integrated network in Georgia with more than 1,800 physicians concentrating in 70 different subspecialties. 6

• Two hospitals within Emory Healthcare, Emory St. Joseph’s and Emory University are Magnet designated hospitals. 6

Beginnings of Lateral Violence

• The American Nurses Association (ANA) defines lateral violence as a set of destructive behaviors occurring between colleagues intended to humiliate, offend, or cause distress.1

• It has been noted The Mother of Modern Nursing, Florence Nightingale’s caustic manner towards nurses of lower social class during the Crimean War planted the seeds for lateral violence to take root in present - day nursing culture. Nightingale’s sarcastic nature throughout her 1859 book “Notes on Nursing” set the tone for the prevailing incivility between nurses.

Beginnings of Lateral Violence

• Examples of sarcastic quotes from Florence Nightingale’s “Notes on Nursing”

– “ But if you cannot get the habit of observation one way or other you had better give up being a nurse, for it is not your calling, however kind or anxious you may be.”12

– “If you wait till your patient tells you, or reminds you of these things (keeping noise down), where is the use of having a nurse.”12

Prevalence

• In a survey conducted by Johnson and Rea (2009), 38% of the participants identified a co-worker as a source of bullying, and 29.5% reported the physician as the source.9

• A 2015 survey conducted by the American Nurses Association of 3,765 RNs found nearly one-quarter of respondents had been physically assaulted while at work by a patient or a patient’s family member, and up to half had been bullied in some manner, either by a peer (50 %) or a person in a higher level of authority (42 %).2

Clinical Exemplar

• W.K., a physician in Minnesota, claimed lateral violence against him by his physician colleagues. One of the claims that he made in court was under contract law for breach of contract with a request for punitive damages (extra money) because he alleged that their breach of the “covenant of good faith and fair dealing” was intentional.13

• The acts included isolating him, ostracizing him, making false statements about him, and threatening his job security. The court concluded that the defendants’ motivations underlying the breach of contract allegations were “immaterial, even if malicious,” and WK was not entitled to punitive damages for the contract claim (Rainford, Wood, McMullen, Philipsen, 2015, pp. 162).

Clinical Exemplar

• Findings from a research study examining workplace violence against nursing students and nurses located in Rome, Italy.

– Italian nurses reported more aggression, threats, and episodes of sexual

harassment. 13.4% of nurses reported at least one physical assault in the previous

year, while the percentage was 6.6% among students. Threats and sexual or verbal

abuse were more prevalent than assaults. 42.5% of nurses and 34.1% of nursing

students had experienced at least one episode of physical or nonphysical violence

at work (Magnavita and Heponiemi, 2011, pp 206).

Clinical Exemplar

• A nurse, JD, alleged that a cardiac surgeon at the Alabama hospital where both worked screamed at him, belittled him, and threatened him. JD reported that he suffered a major depressive episode as a result, had to go on leave. He filed a lawsuit in civil court against the surgeon. The surgeon’s defense was that incident was “ a shouting match between two professionals.” JD’s attorney reported that this was the first case in the US to use an expert psychologist on the issue of workplace bullying. The jury, which included several health care professionals and a registered nurse jury foreperson, returned a unanimous verdict in favor of JD. He was awarded $325,000 (Rainford et al., 2015).

Legal Considerations

• Although there are currently no laws in the United States specifically targeting workplace bullying, as of April 2016, several bills addressing the issue were active in 29 states (The Healthy Workplace Campaign, 2016).

• At the federal level, the Occupational Safety and Health Act of 1970 (OSHA) established the general duty clause, mandating employers to “furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing are likely to cause death or serious physical harm to his employees” (Matt, 2012).

• Some states have their own state safety and health programs, for example in Washington State, the Washington Industrial Safety and Health Act (WISHA) provides that, at the very least, employers have a general duty to ensure a safe and healthy workplace for their employees (Matt, 2012).

Legal Considerations

• Individuals who spread rumors about a colleague may be sued on the basis of defamation

– To prove defamation in a court of law, which includes libel and slander, the plaintiff need only prove that someone either said or wrote something about him or her that was heard or read by a third party (communication) and that caused injury (fault and damages) to the subject of the rumor (i.e. hurt the subject’s reputation).14

– In addition, the rumor must be false, and the statement cannot be privileged.14

– Although abusive statements in themselves may not be actionable, abusive statements that contain falsehoods about individual workers may become actionable.14

– However, despite the seemingly clear elements of a defamation claim, it is difficult to succeed with such a claim because of the courts’ interpretations of the facts of the case and precedent.14

Ethical Considerations

• There are several ethical principles that are violated by nurses who engage in bullying behaviors.

• Nonmaleficence: Above all do no harm.14

• Beneficence: Requires nurses to prevent and remove existing evil or harm and to promote good.14

• Justice: Fair treatment of all.14

Ethical Considerations

• Several virtues that contribute to a moral character for health professionals

– Compassion – Centered on others, assuming “active regard for another’s welfare” and response to another’s suffering of “sympathy, tenderness, and discomfort.14

– Discernment – The virtue of discernment is described as “the ability to make fitting judgements and reach decision without being unduly influenced by extraneous consideration, fear, personal attachments, and the like”.14

– Integrity – Refers to the nurse’s faithfulness to moral values and commitment to standing up for what the nurse discerns as the right thing.14

– Conscience – “A form of self – reflection on, and judgement about, whether one’s acts are obligatory or prohibited, right or wrong, good or bad”.14

Psychological Considerations

• Bullying has negative consequences for the psyche of nurses and for their functioning as an employee within the organization, over and above issues such as the individual’s propensity to see things negatively. 7

• Psychological ramifications:– Diminished social skills

– Depression

– Diminished ability to concentrate

– An inability to cope

– Posttraumatic stress disorder

• Numerous studies have highlighted the significant associations between individual (personality) factors and the exposure to workplace bullying. 7

Psychological Considerations

• A Norwegian study, conducted in a sample of 2200 workers, brought to light that the victims of bullying were characterized by low self – esteem and social competence, and reported high levels of anxiety.7

• In study of 60 Irish victims of bullying, found that bullied individuals were: (1) more anxious and suspicious, (2) less assertive, and (3) had limited emotional coping resources.7

Psychological Considerations

• The profile of an individual who may be prone to be bullied

1. Castronova, Pullizzi, and Evans (2015) state that people who tend to generate new ideas are often bullied because they challenge the status quo of the workplace.

2. Furthermore, Castronova et al., (2015) point out individuals are often bullied because they constitute a threat to someone at a higher level.

• Certain attributes that make people more vulnerable to becoming a target of workplace bullying 3

1. Intelligence

2. Competence

3. Integrity

4. Accomplishment

5. Dedication

6. Loyalty

Physical Considerations

• Health issues stemming from lateral violence– Weight gain or loss– Fatigue– Headaches– Hypertension– Angina

• Even more serious than health consequences is nurse to nurse bullying may lead the victim to commit suicide.– A 2012 survey conducted by the Workplace Institute

showed that 29% of bullying victims contemplated suicide, and 16% had a plan in place for carrying it out.17

Occupational Considerations

• Low job satisfaction

• Work absences

• Poor productivity

• Propensity to leave the job

Conflict Resolution

• In simplistic terms, conflict resolution means to resolve a disagreement or dispute.

• There are many methods of resolving conflict, however, open communication and role playing will be the focus during this dialogue.

Conflict Resolution

• What we say, how we say it, and what we mean, by it are extremely important, and can be life changing (Vertino, 2014).

• Words spoken by nursing leaders, educators, and mentors have the power to either help younger professional nurses blossom within their careers or to destroy their self – esteem.

Conflict Resolution

• Open Communication– When two individuals are communicating openly they

have created an open dialogue of mutual exchanges of ideas and perceptions. Open communication may be unsuccessful if trust is not apparent from both parties.16

• Open communication is needed to relate to one another as human beings around the world in the context of relationships, families, organizations, and nations (Vertino, 2014).

Conflict Resolution

• Three elements of communication– Sender– Receiver– Message

• We must be aware of factors which may influence how the message is interpreted. Healthcare professionals must consider the setting in which the communication occurs, the past experiences and personal perceptions of both the sender and receiver and the timing of the message.16

Conflict Resolution

• Personal variables: Internal predisposing factors(Vertino, 2014)

YOU

Thoughts, feelings,

perceptions, values

Experiences, education, roles, skills,

abilities

Gender, genetics, culture,

upbringing, history

Personality, voice,

presentation, style

Conflict Resolution

• Role Playing

– Takes place between two or more people, who act out roles to explore a particular scenario. 10 The bullying perpetrator and victim may act out an alleged incident of lateral violence.

– The hope is the perpetrator would gain a sense of clarity and empathy by placing themselves in the role of victim. 10

Conflict Resolution

• Role Playing Rules 8

- Must be focused

- The objectives and instruction must be clear and understood

- Feedback needs to be specific, relevant, achievable and given immediately

Conflict Resolution

• While using conflict resolution techniques to solve a problem remember to keep an open mind and discuss solutions respectfully when conflict arises.

• Remember, it is ok to disagree; yet it is essential to maintain a spirit of cordial relations amongst colleagues who may have offended you.

Implementation

• Emory Healthcare’s Care Transformation Model 5

Implementation

• Emory Healthcare’s Pledge

• Four basic tenets 5

– We will treat each other the way we want to be treated

– We will cultivate a spirit of inquiry

– We will defer to each others expertise

– We will communicate effectively

One Step Further

• Proposed Workshop• Purpose: To reduce nurse – to – nurse lateral violence and

create a more respectful workplace culture in our organization through a series of strengthening communication workshops (Ceravolo, Schwartz, Foltz – Ramon, & Castner, 2012).

• This quality improvement project described in Ceravolo et al., 2012’s research paper took place within a five – hospital integrated health – care delivery in the north – eastern USA from 2008 to 2011.

• The 60 to 90 minute workshop were designed to enhance assertive communication skills and raise awareness about the impact of lateral violence behaviors (Ceravolo et al., 2012).

One Step Further

• Emphasis in all of the workshops was placed on healthy conflict resolution and eliminating a culture of silence for nurses.4

• Nurse managers were the first to attend the workshops. The managers were expected to serve as role models for their employees modeling the behavior they had learned in the workshop.4

• The next group of nurses that were trained was staff working in units with high turnover rates.4

• A “train the trainer” workshop, was created, which trained 20 staff nurses and educators on the content and presentation skills. 4

One Step Further

• Staff nurse trainers co – presented the workshops in teams of two in order to grow confidence in our new trainers and minimize anxiety regarding presenting to their peer group. 4

• After the first year of workshops, in 2009, a presenter debriefing session was held to provide an opportunity for nurses to learn from one another. 4

• As the project gained momentum, workshops were presented around the clock and scheduled based on managers’ perception of when staff nurses would attend. The workshops were also presented at area nursing schools at the request of faculty. 4

One Step Further

• After 2009, the conflict resolution and lateral violence content of the workshop was assimilated with the adoption of the nationally recognized Team STEPPS curriculum. 4

Team Structure

Identification of the components of a multi-

team system that must work together

effectively to ensure patient safety

Communication

Structured process by which information is

clearly and accurately exchanged among

team members

Leadership

Ability to maximize the activities of team

members by ensuring that team actions are

understood, changes in information are

shared, and team members have the

necessary resources

Situation Monitoring

Process of actively scanning and assessing

situational elements to gain information or

understanding, or to maintain awareness to

support team functioning

Mutual Support

Ability to anticipate and support team

members’ needs through accurate knowledge

about their responsibilities and workload

One Step Further

Conclusion

• Decreasing lateral violence must be a priority for nurses. By diminishing lateral violence and enhancing a workplace culture of respect, it can be inferred that these previously mentioned interventions will also enhance outcomes for fellow colleagues as well as the organization.

Acknowledgements

Maggie Carvalho MHA, MSN, RN

Assistant Director, Enterprise Staffing Pool

Emory Healthcare

Michelle Gray RN MN NEA-BC

Director, Care Transformation

Emory Healthcare

References

1. American Nurses Association, Position Statement on Incivility, Bullying, and Workplace Violence. (2015). Report of the ANA Position Statement on Incivility, Bullying, and Workplace Violence. Retrieved from http://nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-Statements-Alphabetically/Incivility-Bullying-and-Workplace-Violence.html

2. American Nurses Association. (2015). ANA sets ‘zero tolerance’ policy for workplace violence, bullying. Retrieved, April 4th, 2016 from http://nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2015-NR/ANA-Sets-Zero-Tolerance-Policy-for-Workplace-Violence-Bullying.html

3. Castronovo, M.A., Pullizzi, A., & Evans, S. (2015). Nurse bullying: a review and a proposed solution. Nursing Outlook, 10, 1 – 7. doi: 10.1016/j.outlook.2015.11.008

4. Ceravolo, D.J., Schwartz, D.G., Foltz-Ramos, K.M., & Castner, J. (2012). Strengthening communication to overcome lateral violence. Journal of Nursing Management, 20, 599 – 606. doi:10.1111/j.1365-2834.2012.01402.x

5. Emory Healthcare. (2016). Care transformation model. Retrieved, April 4th, 2016 from http://www.emoryhealthcare.org/quality/care-transformation/index.html

6. Emory Healthcare. (2016). About Emory healthcare. Retrieved July 11, 2016 from http://www.emoryhealthcare.org/about-us/index.html

7. Giorgi, G., Perminiene, M., Montani, F., Fiz-Perez, J., Mucci, N. & Arcangeil, G. (2016). Detrimental effects of workplace bullying: impediment of self – management competence via psychological distress. Frontiers in Psychology, 7(60), 1 – 11. doi: 10.3389/fpsyg.2016.00060

8. Harbour, E. & Connick, J. (2008). Role playing survey and activities rules and tips. Retrieved, April 4th, 2016 from http://www.businessballs.com/roleplayinggames.htm

References

9. Johnson, S.L. & Rea, R.E. (2009). Workplace bullying: concerns for nurse leaders. Journal of Nursing Administration, 39(2), 84 –90. doi: 10.1097/NNA.0b013e318195a5fc

10. Lee, Y.J., Bernstein, K., Lee, M. & Nokes, K.M. (2014). Bullying in the nursing workplace: applying evidence using a conceptual framework. Nursing Economics, 32(5), 255 – 267. Retrieved from http://search.ebscohost.com.proxy.chamberlain.edu:8080/login.aspx?direct=true&db=her&AN=98979421&site=ehost-live

11. Magnavita, N. & Heponiemi, T. (2011). Workplace violence against nursing students and nurses an Italian experience. Journal of Nursing Scholarship, 43(2), 203 – 210. doi: 10.1111/j.1547-5069.2011.01392.x

12. Nightingale, F. (1860). Notes on nursing, what it is, and what it is not. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html#II

13. Rainford, W.C., Wood, S., McMullen, P.C., & Philipsen, N.D. (2015). The disruptive force of lateral violence in the health care setting. The Journal for Nurse Practitioners, 11(2), 157 – 164. doi: 10.1016/j.nurpra.2014.10.010

14. Matt, S.B. (2012). Ethical and legal issues associated with bullying in the nursing profession. Journal of Nursing Law, 15(1), 9 –13. doi: 10.1891/1073-7472.15.1.9

15. The Healthy Workplace Campaign. (2016). State of the union: state activity. Retrieved April 4th, 2016 from http://healthyworkplacebill.org/states/

16. Vertino, K. (2014). Effective interpersonal communication: a practical guide to improve your life. OJIN, 19(3), http://www.ncbi.nlm.nih.gov/pubmed/26824149

17. Workplace Bullying Institute (2015). Mental health harm: psychological-emotional-mental injuries. Retrieved April 4th, 2016 from http://www.workplacebullying.org/individuals/impact/mental-health-harm