Kathleen Bartholomew presentation - Ontario Nurses' Association

Ending Nurse-to-Nurse Hostility
Ontario Nurses’ Association Human Rights and
Equity Caucus Meeting
Presented by: Kathleen Bartholomew, RN, MN
November 19, 2012
Ontario Nurses’ Association
www.ona.org

Healing RN-RN Hostility
Tell Me Your Story…
Kathleen Bartholomew, RN, MN
kathleenbart@msn.com
Seattle, Washington

“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

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 recipient
2. Must be a negative effect on victim
3. The bullying behavior must be consistent
(Quine, 1999)

Overt:
name-calling, sarcasm, bickering, faultfinding,
back-stabbing, criticism,
intimidation, gossip, shouting, blaming, putdowns,
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.

Most Frequent Forms
• Nonverbal innuendo (raised eyebrow, faces)
• Verbal affront (covert or snide remarks)
• Undermining activities (being unavailable)
• Withholding information (practice or patient
• Sabotage (deliberately setting up a negative
situation)
J. Advanced Nursing ‘97

WA State ER Nurses
• Withholding information 45%
• Ordered to do work below competence 40%
• Opinions and views ignored 33%
• Pressure not to claim something 28%
• Key areas of responsibility removed 27%
• Being ignored or excluded 25%
JONA Vol. 39 No 2

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)

Why do nurses minimize HH?
• Doesn’t match virtue image
• They also do it
• Too close – focus is on workload
• Don’t know how to confront behavior
• Low confidence/self-esteem
• “Herd Mentality” – they expect hostility
Farrell, 2000

International Prevalence
44% reported “bullying”
Bullied staff had lower job satisfaction
higher stress, depression, & anxiety
and higher intent to leave
33% were intending to leave because of
verbal abuse

United States
Empirical studies
1. 82% witnessed in last yr.
2. 77% saw negative RN-RN behaviors
2. 28% in survey of US occupations (16)
2. 31% Mass. Study (15)
3. 27.3% bullied in last 6 mo. (17)
4. 46% reported serious LV behaviors (2)
- Verbal abuse from physicians 90-97% (9)

“Of all types of
aggression
nurses experience,
peer to peer
hostility is
the most harmful.”
Farrell, 1999

Individual Impact
- Psychological, physical, emotional, social
- Direct relationship btw conflict and burnout
- Decreased job satisfaction and morale
- Increased intent to leave

“All too often we leave the workplace
bone tired and soul weary, trying to
shake off the sticky residue of moral
distress, that awful realization that we
could not give patients the care they
deserved.”
Thomas (2004)

Human Adaptability
Changes that are small and
incremental are not noticed

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.

OBJECTIVE
CURE
SCIENCE
LEFT BRAIN
SUBJECTIVE
CARE
ART
RIGHT BRAIN

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)

Life Classic Photographs by J. Loengard

Life Classic Photographs by J. Loengard

“What will we do with all this spare time?

Emotions running strong…
Because nurses
- do emotional work
- 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”
• Intergenerational conflict
• Inadequate conflict management skills
• Intermittent reinforcement is strongest
• Beliefs and expectations

Extrinsic Factors
• Violent workplace
• Poor nurse-physician relationships
• Task and time imperatives
• Changing role/responsibilities of managers
• Demands for efficiency/productivity
• Culture – history of no feedback

Impact on Profession of Nursing
- Recruitment/ Retention in a shortage
- Lack of staff due to increased sick days
related to stress and burnout
- Creates a toxic work environment
- Failure of nursing to achieve solidarity
- Patient safety: can’t think clearly when
upset

“What we need is what the
ancient Israelites called hochma
…the capacity to see, to feel and
then to act as if the future
depended on you.
Believe me, it does.”
Bill Moyer

Response: Strategies and Tools
1. Decrease negativity, gossip and a culture of blame
by 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 confrontation
skills.

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

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”

“ If you want to create
an alternative future,
you have to change
the way people speak
and listen to each other”
Peter Block

JCAHO Statistics*
*http://www.jcaho.org/accredited+organizations.htm

“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)

The
Grey
Zone

“When someone dumps their toxic
feelings on us…they activate in us
circuitry for those very same
distressing emotions.
Their act has powerful neurological
consequences: emotions are
contagious.”
Daniel Goleman

What do you say after you hear that
someone has been backstabbing you?

SIP Communication Model
Situation - Describe the situation in
specific, observable, behavioural terms
Impact - Share the impact the behaviour had
on the organization, on the team, or on you
Pull - piece - See it through their eyes

S
"When you delivered the work to me two
days late...“
I
"I ended up scrambling and was unable
to meet the patient need“
P
"Can you tell me what was going on for
you?

You are late for report and as you
open the door you hear,
“I hate to follow Kathleen - she’s
always dumping on the next shift.

S – When I walked into the report room, I
heard….
I - I was upset, because I was unaware that
anyone in the next shift thought I was
leaving things…
P - Can you tell me what it’s been like for
you to follow me, and specifically what
you’ve found?...

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?

S I recognize you have a heavy workload. This
morning when I walked into your office you seemed
bothered by my questions and I felt in the way.
I The impact on me was that I felt ignored and
unimportant - like you wished I wasn't there. The
impact on the patient was that I wasn’t comfortable
enough to find the answers I was looking for.
P I want to learn and be the best nurse I can be.
Can you help me understand what was going on for
you? Is there another way I could have approached
you to get information?

• Ask for what you need
• It isn’t a request,
if you expect a ‘yes’

To thrive horizontal hostility needs:
secrecy
shame
silent witness

Sample Questionnaire
I am respected by my peers 1 2 3 4 5
I feel supported by my peers 1 2 3 4 5
I can safely express my opinions 1 2 3 4 5
I feel a strong sense of belonging 1 2 3 4 5
What I like the most about my team is_____________
What I need more from this team is ______________

Ask For Feedback
• What do you like that I do
well?
• What would you like to see
more of?

Nurturing Our Young
“ The profession of nursing has an
obligation to reduce lateral violence...
Griffin 2004

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

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

to
Responding
to
Horizontal Hostility
Non-verbal inuendos (raising eyebrows or 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”

Link safety and the relationship…
• 67% saw link between disruptive behavior
and medical mistakes
• 18% knew of a mistake that occurred
because of an obnoxious doctor
(Rosenstein)
• 40% withheld medication concerns;
As a result, 7% contributed to med error
(Safe Medication Practices)

Action Plan for New Nurses
1. Teach cognitive rehearsal skills in nursing school
2. Student nurse feedback to preceptor
3. Utilize a coaching model for education
4. Share a meal 1:1 in the first 2 weeks
5. Affirm individual contributions
6. Make the time for reflective practice
7. Adopt a mentorship program
8. Decrease precepting nurse’s workload
9. Share a story from your first week

RN Action Plan
1. Be aware of the signs and symptoms of HH
2. Understand the many forces nurses affecting
nurses today
3. Speak your truth – hold crucial conversations
4. Adopt a zero tolerance unit philosophy
5. Take care of yourself

Revolutionary New Nurse Beliefs
• A good nurse takes care of herself
• A good nurse needs the help and support of
her peers
• A good nurse seizes the details of a mistake
and shares them to improve practice
• A good nurse speaks her truth at all times
• A good nurse nurtures and feeds new nurses
• A good nurse demonstrates professionalism

6. Evaluate your belief system
7. Take the time to reflect on your practice
8. Education
- Assertiveness training
- Confrontation skills – DESC model
- Juice “Pull Conversation” skills
- Non-violent communication
8. Compliment each other – often!
9. Provide opportunities for socialization
10. Never be a “silent witness”
11. Ask for feedback – peer review

AJN Faces of Caring

AJN Faces of Caring

Thank you!
• Kathleen Bartholomew
• kathleenbart@msn.com
• 206-356-2599
• www.kathleenbartholomew.com