Saturday February 24th 2018

Toward civility

ANA, nurses promote strategies to prevent disruptive behaviors

Code red. Code blue. Code pink?

While the first two codes are universally known to nurses, the less familiar, “code pink” can refer to a technique nurses employ to address unacceptable behavior in hospitals and other settings. It works like this: RNs go to the location where their nurse colleague is being verbally abused and stand in support of their peer — and against the bullying that is taking place.

It is one tactic, developed by OR nurses, that can help stem the tide of incivility, bullying and other forms of lateral violence. And more strategies are definitely needed within the work environment — be it an OR, an academic institution or a med-surg unit, say nurse experts.

Incivility is not just happening in health care. In a January-February 2013 Harvard Business Review article, researchers found that 98 percent of respondents, including lawyers, architects, coaches and physicians, reported experiencing uncivil behavior at work.

Yet incivility seems even more vexing a problem in health care, where “care” is supposed to reign. To help address bullying, the American Nurses Association (ANA) has created resources, including a publication, tip cards, fact sheet and webinars, that offer strategies for both individual nurses and organizations to use. ANA also has posed questions on workplace violence and bullying as part of its Health Risk Appraisal, an online survey available to all nurses. And nurse experts around the nation are promoting ways to ensure a better and safer environment for all.

Joy Longo, PhD, RNC-NIC, an associate professor of nursing at Florida Atlantic University, focuses her research on bullying and has written extensively on ways to promote a healthy work environment, including a Jan. 31, 2010 article in the Online Journal of Issues in Nursing. She also addressed this issue for an ANA Navigate Nursing webinar in 2011.

“It’s a factor in the work environment that can affect patient safety,” said Longo, a Florida Nurses Association member. “If even one [untoward] encounter a day causes a medication error, that is one too many.”

Starting at the beginning

Cynthia Clark

Cynthia Clark, PhD, RN, FAAN, ANEF, a professor of nursing at Boise State University, an Idaho Nurses Association member and the author of Creating and Sustaining Civility in Nursing Education, has been studying incivility — a range of uncivil behaviors — and ways to foster civility and healthy academic and practice work environments for more than a decade.

“When I first started studying the topic of civility and incivility, very few people wanted to discuss it much or admit that it was an issue in health care or in schools,” Clark said. “Now it’s a hot topic.”

Clark sees incivility as a continuum, with disruptive behaviors, such as eye-rolling and other nonverbal behaviors and sarcastic comments, on one end of the spectrum, and threatening behaviors, such as intimidation and physical violence, on the opposite end.

Her exploration of this topic began when she witnessed certain behaviors among some nursing students that were similar to those she saw while practicing clinically at treatment centers for violent youth.

“They [some students] were not outwardly hostile, but they displayed rude, disruptive behaviors and acted with a sense of entitlement,” Clark said. When she asked other faculty whether they encountered similar behaviors, they acknowledged that they had. Clark and colleague Pamela Springer, PhD, RN, surveyed faculty and nursing students about the uncivil or impolite behavior they experienced. Faculty reported behaviors such as students talking over others, using their cellphones in class and making disparaging comments about faculty between classes. Students described negative faculty behaviors that included making condescending remarks, using outdated and ineffective teaching methods, and criticizing students in front of peers.

Through ongoing research, Clark has found that students and faculty are concerned about incivility, and would like to learn how they can more easily recognize and address it. And it can occur between anyone: student to student, student to faculty, faculty to student, academic peer to peer, faculty to administrator, and vice versa.

Inappropriate behavior can be fueled by many stressors. Clark found that student stressors include: demanding workloads and meeting deadlines, juggling work, school and family responsibilities, academic incivility, competing for grades and worrying about harming patients.

Nursing faculty are stressed by factors that include dealing with constant change, managing heavy workloads and other obligations, working toward tenure, and coping with problematic students and faculty incivility.

“Some workplaces and learning environments are healthier than others,” Clark noted.

Given these stressors, she offers some strategies to improve the faculty-student relationship and reduce incivility for both parties, which she detailed in the article, “The Pedagogy of Civility: Innovative Strategies to Create an Engaged Learning Environment.”

Role-modeling positive behaviors is key. Clark suggests, for example, that faculty send an email welcome message, which includes a greeting and course information, to students before class begins.

She also recommends that faculty ask students to help create classroom norms that specify, for example, which behaviors they want and don’t want in their learning environment and how those norms will be enforced.

“Some common examples include role-modeling the type of nurse each of us aspires to be, communicating respectfully, and negotiating conflicts directly and honestly,” she said.

Another key strategy requires a shift in thinking on the part of students and faculty alike. Students should take a more active role in their learning, develop their ability to work in teams and view faculty not as imparters of knowledge but as “facilitators of learning,” according to Clark. Faculty also need to move away from the idea of being the expert, and instead, the facilitator of student learning and engagement. Using “just-in-time” teaching techniques and involving students in simulated and active “in-situ” learning experiences deepen their understanding and improve their ability to think like a nurse.

“There always will be a power differential between students and faculty,” Clark said. “And each of us, including academic leaders, students and faculty, has a shared responsibility to examine our own behaviors and to reflect on how we may be contributing to the situation.”

Longo agreed, saying that it’s critical to address disruptive behaviors — including cyber-bullying — in schools of nursing, because those behaviors can affect patient care.

Going into the workplace

When it comes to incivility, Longo said, “Everybody is accountable for their own behaviors and actions.”

That said, leadership within an organization has a huge role.

Nancy Davis

A current member of the Louisiana Board of Nursing, Nancy Davis, MN, MA, RN, NE-BC, recently retired as chief nursing officer of a large health care system in the New Orleans, LA, region. During the course of her career, she has witnessed incivility or bullying at many levels. She recalled a surgeon whose rude and demeaning comments to scrub nurses made them unwilling to work with him. She’s seen incivility play out on a critical care unit, which took the form of hazing.

“The attitude [among experienced staff] was we’re good, and you’re going to have to earn your stripes — like in the NFL,” said Davis, a Louisiana State Nurses Association member.

That behavior is something that, as a CNO, she didn’t want occurring.

“Leaders set the tone for the culture of an organization, and what you allow is what you get,” Davis said.  About 15 years ago, she and the chief medical officer collaborated on a “zero tolerance” policy against incivility — whether it involved peer to peer, supervisor to manager, or executive to manager.

Davis acknowledged that it took a couple of years to take hold, because they had to raise the consciousness among staff and physicians about problematic behaviors, which can take on subtle forms.

“We didn’t want it to be about blame, but setting up boundaries [of acceptable behaviors] and backing up nurses and others who reported someone who was violating the policy,” Davis said.  She also wanted to ensure that the offending party — even if it was a physician known as a “big admitter” — was dealt with fairly, but appropriately.

She added that managers were given resources and more education to identify and address unacceptable behavior.

Spreading the word

Judi Seltzer

To help promote better work environments nationwide, Judi Seltzer, MS, BSN, RN, CNOR, co-presented a recent webinar, called “Zero Tolerance for Lateral Violence: Changing the Culture of Nursing Practice,” for the Association of periOperative Registered Nurses (AORN), a premier organizational affiliate of ANA.

In the webinar, Seltzer, and her colleagues Lori Ingram, MSN, RN, CNOR, and Angi Walsh, MA, BSN, RN, CNOR, spoke about common types of lateral violence that nurses encounter in their workplaces and offered strategies — such as calling a “code pink” — to address unwanted and escalating behaviors, including from patients and families.

“We asked nurses attending the webinar if they had been bullied, and more than 90 percent said they had,” Seltzer said. No age or experience level seemed to be immune. New nurses reported bullying from their ill-matched preceptors during orientation. Older nurses described younger nurses rolling their eyes or making comments about them if they had difficulty learning new technology.

And unfortunately, some nurses still accept various forms of violence as being part of their job, said Seltzer, an AORN and ANA member. “They need to recognize overt and covert lateral violence, like gossiping and sabotaging assignments, as unacceptable,” she continued. “And they need to be empowered to speak up when they encounter these behaviors without fearing retribution.”

To make that happen, it takes a “top-down” approach in which leaders provide staff and non-staff with comprehensive training, including ways to strengthen their communication skills, Seltzer said. Leaders further must develop written policies with key stakeholders’ input.

At the webinar, nurse presenters shared a range of directives, position statements and policies from varying organizations, including The Joint Commission, AORN and ANA, emphasizing that disruptive behavior has no place in health care. Nurses can use these resources to advocate for civility policies, as well as to gain support for other healthy workplace strategies, according to Seltzer.

Longo, who supports the development of codes of conduct and educational initiatives to reduce disruptive behavior, added that workplace policies must be clear in terms of behaviors and consequences. Those consequences must be applied uniformly and consistently.

She said it is equally important “to take a step back and look at what is going on in the work environment. Is it fair and just?”

Health care is very stressful. Patient-loads are heavy, and staffing is an ongoing issue, she said. These stressors can contribute to incivility, so they too must be addressed.

“We all need to be honest at looking at our behavior and sensitivities, and be proactive in our work environment if we want to reduce incivility and disruptive behavior,” Longo said.

— Susan Trossman is the senior reporter for The American Nurse.


ANA’s Healthy Nurse Environment and documents on bullying and lateral violence:

ANA’s Health Risk Appraisal:

AORN’s webinar on lateral violence:

The Joint Commission alert on disruptive behavior:

American Association of Critical-Care Nurses Healthy Work Environment:

U.S. Occupational Safety and Health Administration on workplace violence in health care:

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