Creating a healthy environment while simultaneously decreasing hostility is the most effective approach that leaders can take to enact change at the organizational level, a nurse leader says.
The nursing profession routinely tops the list of Gallup's annual survey that measures public opinion of the most trusted occupations regarding honesty and ethical standards. Yet, what the public may not realize is that inside the nursing profession, there are reports of bullying, incivility, and disruptive behaviors among nurses, creating unethical situations within healthcare work environments.
Disruptive behaviors among nurses have become so pervasive that the American Nurses Association (ANA) created a policy in 2015 in an attempt to reduce them.
According to the ANA position statement, nurses must "create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect." Key points of the position statement include:
- The nursing profession will not tolerate violence of any kind
- Nurses and leadership must work together to create a culture of respect
- Evidence-based strategies to prevent and mitigate incivility, bullying, and workplace violence must be adopted
Additionally, The Joint Commission issued a Leadership standard in 2008 (LD.03.01.01) that addresses disruptive behavior in two elements of performance (EP). Specifically, the healthcare organization must have a code of conduct that defines acceptable behaviors as well as disruptive. Further, The Joint Commission requires that healthcare leaders have a process in place to manage both behaviors.
Mitigate disruptive behaviors
Disruptive behaviors among nurses can include refusing to work with a particular nurse, ignoring a call to help with a patient that requires multiple nurses, and ostracizing a nurse without explanation, as examples. Kathleen Bartholomew, RN, MN, author of Ending Nurse-to-Nurse Hostility, says that nurse managers need to get on the unit and observe behaviors, especially at shift change. "They need to watch for the non-verbal [clues], such as raising eyebrows, making faces, etc., and make it about ALL of us as a team instead of an individual issue," she says.
What are some actions nurse leaders can take to reduce these behaviors? Jenny Shrapnel, BSN, PICU manager at Rady Children's Hospital in San Diego, and Bartholomew recommend:
- Observe the staff in action. How is the staff interacting with each other? Are there cliques?
- Conduct staff surveys. Send out annual staff surveys to gauge engagement. Bartholomew recommends surveying the newest nurses about their experiences, "Did we make you feel welcome at all times?"
- Set clear expectations with the nursing team about which behaviors are acceptable and which are not.
- Don't listen to gossip. Both Bartholomew and Shrapnel stress the importance of nurses finding out the facts of any complaint before reacting.
- Educate staff about appropriate behaviors in meetings. To help combat disruptive behaviors in her unit, Shrapnel holds 30-minute educational sessions during her monthly meetings.
The consequences of disruptive behavior can lead to a decrease in morale and affect retention, and cause burnout, and it can also indirectly affect patient safety, says Shrapnel. "If you have a nurse causing disruption, the behavior could have a detrimental effect on the patient."
According to a 2008 survey of healthcare professionals, 71% of respondents felt disruptive behaviors were linked to medical errors, 27% felt disruptive behaviors were linked to patient mortality, and 18% were aware of a specific adverse event as a result of disruptive behaviors.
Strategies in action
After a string of disruptive behaviors on her unit and low employee engagement scores indicating a need for updated processes to manage the behaviors at Rady Children's, Shrapnel reevaluated how to more effectively address this issue.
In a joint decision, Shrapnel and the organization's leadership sent out a staff survey to determine whether disruptive behaviors were still an issue and to gauge if there had been any improvement. The results were unchanged from the previous year.
"The results hadn't changed at all, [along with] the employee engagement scores; the nurses needed help," she says. "And that's when I took the bull by the horns."
As a first step, Shrapnel had the nursing team undergo DISC personality testing. The goal of the testing was to help the team members understand the strengths and weaknesses of each personality type. Therefore, when communicating with other nurses, they had a better understanding of how receptive the other person would be to the conversation and how to address individuals based on their personality type, Shrapnel explains.
"The AACN standards say we must be as competent in our communication skills as we are in our clinical skills," says Bartholomew. "As a profession, we are missing a critical skill set."
Role-playing was also a way to practice positive communication among nurses. During a recent education session, Shrapnel paired the nurses into groups and had them discuss real examples of difficult conversations or conflicts they've had with other nurses. Shrapnel then provided handouts to the groups that helped them brainstorm how they can respond in a positive way when a similar situation occurs.
The communication strategies that Shrapnel has implemented are relatively new, but there has already been a noticeable change in the work environment and not just with the staff on her unit. A former colleague and consultant on disruptive behaviors visited the floor recently and remarked that the attitude and environment is completely different from just a few months ago, Shrapnel says.
By providing the tools to more effectively communicate with each other, the staff is working as a team and the clique that once existed on the floor has dissipated. "This is still a work in process, but this has made an improvement for the team," Shrapnel says.
Power of teams
In Bartholomew's book, she says that creating a healthy environment while simultaneously decreasing hostility is the most effective approach that leaders can take to enact change at the organizational level. She says leaders must firmly establish board and senior leadership team commitment to decrease hostility and make harm visible. Making harm visible means framing disruptive behavior as a safety issue, she says, while also stressing the importance of working as a team.
The effect on teamwork cannot be minimized. Teams that work together well produce respect and trust, Bartholomew notes.
She says by shifting the power structure from a hierarchy to a team/tribe, you:
- Provide a constructive feedback system for accountability and performance
- Provide leadership training and confrontation skills training for managers
- Provide assertiveness training and confrontation skills training for managers
- Monitor the organizational climate
- Increase social capital—build a strong informal network
Editor's note: This story was updated on May 17, 2019.