CIVILITY IN THE WORKPLACE

1. CIVILITY IN THE WORKPLACE Workplace Sub-Committee Commission on the Crisis in Nursing

2. CIVILITY IN THE WORKPLACE • Commission on the Crisis in Nursing • Workplace Subcommittee • J. “Ski” Lower, RN • Linda Jefferson, RN • Leslie Simmons, RN • Kathy Agnes • Jane Flowers, RN • Jacky Young

3. WORKPLACE SUBCOMMITTEE CHARGE • To explore the major factors contributing to the nursing shortage and recommend actions • We have examined the impact of one factor, the culture of disrespect, on the nursing shortage, patient safety, team work and the economic bottom line

4. OUR CHALLENGE IS CLEAR • BOLD AND INNOVATIVE ACTION IS NEEDED NOW!! • Nurses will leave and contribute to the nursing shortage. • Nurses will stay, tolerate the abuse, and contribute to a different problem: patient safety

5. PATIENT SAFETY • Nurses who feel intimidated • Will avoid communicating with the MD • Will not question inappropriate orders • Will not speak up as a patient advocate • Will not report their observations

6. ECONOMIC IMPACT • Sick calls • Loss of productivity • Decreased commitment to the organization • Medication errors • Malpractice consequences • Cost of orientation

7. THE PRESENTATION • Introduction • Overview • Seven challenges • Specific recommendations • Examples • Supporting statements

8. CIVILITY IN THE WORKPLACE • OVERVIEW

9. CIVILITY • Civility is behavior that: • Shows respect toward another • Causes another to feel valued • Contributes to mutual respect, effective communication and team collaboration

10. LACK OF CIVILITY • Verbal Abuse • Physical Abuse • Sexual Abuse • Negative behavior

11. 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, MD insulting the RN’s knowledge in front of patient/family, threat, racial or ethnic jokes, criticizing others in public, argumentative behavior.

12. Physical Abuse • Assault and battery • Throwing objects (instruments or charts) • Outbursts of rage or violence (hitting the wall).

13. Negative Behavior • 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, unethical or dishonest behavior, ineffective, nonproductive forms of conflict resolution, repeated failure to respond to a call, lack of respect, cultural bias.

14. WHERE IT OCCURS • Said directly to the person • Said to others • On the phone • Via email • In the medical record

15. WHO IS GUILTY? • Physicians Nurses • Patients Families • Support staff Supervisors

16. CODES OF CONDUCT • Many institutions have these as well as policies for dealing with disruptive behaviors • These documents cannot stand alone to create a culture of civility • More is needed !!

17. Nursing Code of Ethics • Does not identify what conduct is disruptive • Does not identify a procedure for reporting or reviewing reports of disruptive behavior.

18. ANA’s BILL OF RIGHTS FOR NURSES • Nurses have the right to practice in environments that allow them to act in accordance with professional standards and legally authorized scopes of practice • Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance with the Code of Ethics for Nurses and its interpretive statements

19. ANA’s BILL OF RIGHTS FOR NURSES • Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution • Nurses have the right to a work environment that is safe for themselves and their patients

20. LACK OF CIVILITY: CONSEQUENCES

21. Patient Safety • Baggs & Mushlin • For each increase of one point in collaboration, the odds of a negative outcome decreased by 4%

22. Patient Safety: ISMP Survey • 49% of all respondents stated that their past experiences with intimidation had altered the way they handle order clarification or questions about medication orders. • 75% of respondents asked colleagues to help them interpret or validate an order, so that they did not have to interact with an intimidating prescriber.

23. Patient Safety: ISMP Survey • 79% of respondents encountered a reluctance or refusal to answer questions or phone calls. • 87% encountered impatience with questions. • 7% of respondents reported that they had been involved in a medication error during the past year in which intimidation clearly played a role.

24. Patient Safety:RN-MD Interactions • Elaine Larson reported that: • Investigators found significant correlations between physician-nurse collaboration and nurse satisfaction and self-esteem. • If physicians and nurses are in conflict, an unhealthy work environment ensues. • Patient needs are neglected when there is a lack of collaboration with physicians.

25. Patient Safety:RN-MD Interactions • Collaborative interaction between nurses and physicians on critical care units significantly related to mortality rates and length of stay in the units. • A national ICU study showed an association between higher levels of nurse physician collaboration, and lower than expected lengths of stay and lower nurse turnover.

26. Patient Safety:RN-MD Interactions • Jeff Driver, JD Chief Risk Officer of Beth Israel-Deaconess “It is most insidious when nurses are reluctant to tell physicians important observations about patient status. Care can be jeopardized when nurses concentrate on getting physicians under control rather than watching patients at critical moments…”

27. Patient Safety:RN-MD Interactions • Physicians who insult nurses’ in front of patients, families, and staff cause them to question the nurses’ competence and advice according to Bonifazi.

28. Economics • Rosenstien reports on a survey conducted by VHA, Inc. that: • 90% of survey participants reported witnessing disruptive physician behavior. • 33% of participants reported knowledge of a nurse leaving an institution because of disruptive behavior. • 66% of participants reported that their organizations had codes of conduct in place, but less than 50% felt that they were effective.

29. Economics • The most common circumstance stimulating disruptive behavior was placing calls to physicians to clarify orders. • When asked how important a factor disruptive behavior is for nurse satisfaction and morale, the total group response was 8.01 (on a scale of 1-10 with 10 being the highest), the highest score in the survey.

30. Economics • Nursing is Not About the Money. Nursing Wounds U.S. News & World Report. • American Journal of Nursing survey found that the workplace environment was an even stronger factor than compensation when it came to nurse satisfaction. High salaries and bonuses may be offered but it doesn’t matter, nurses won’t stay at a place that has an abusive environment.

31. Teamwork It is almost impossible to have effective teamwork and communication if team members feel intimidated by others, according to Bonifazi.

32. Teamwork • To achieve “magnet status”, a hospital must be able to demonstrate collaborative relationships between nurses and physicians. Kramer stresses that RN/MD relationships must be: • Collaborative: willing cooperation based on mutual power • Collegial: physicians treat nurses as equals • Student/teacher: doctors teach nurses and RN’s teach and influence doctors.

33. Collaboration • An interaction… “ between a doctor and a nurse that enables the knowledge and skills of both professionals to synergistically influence the patient care being provided.” Weiss, SJ. Nursing Resources 1985;34(299-305)

34. Collaboration Process of joint decision making among independent parties involving joint ownership of decisions and collective responsibility for outcomes.

35. Trust The willingness to rely on others under conditions of risk and the expectation that other’s behavior is predictable & beneficial.

36. Constructive Controversy Open-minded discussion occurring within a strong cooperative context, of various perspectives that allows disagreement & exploration

37. CHALLENGE #1 • To increase the awareness of all members and all levels of the health care team and to stimulate a call to action

38. RECOMMENDATIONS: #1 • Survey the multidisciplinary staff, including students within the multidisciplinary teams who utilize the institution for their clinical practicum. The survey should be designed to determine their perceptions regarding the quality of relationships, communication, and roles and any “hierarchical” or stigmatizing attitudes • Have open dialogue with all members of the health care team, using the results of the survey.

39. RECOMMENDATIONS: #1 • Hold open forums to discuss the topic and define workplace intimidation and the process for handling such situations. Give examples specific to your institution to illuminate the reality of the problem and invite discussion. • Invite a guest speaker to give a presentation about disruptive behavior, to present national data, and institutional examples. • Analyze stressors and systems’ issues contributing to lack of civility and begin to lay the groundwork for significant changes.

40. STRESSORS FOR RNs • Staffing • Assignments • Caseloads • Patient acuity

41. STRESSORS FOR MDs • Nurses placing calls to them • Nurses questioning or seeking clarification of their orders • Feeling their orders were not carried out correctly or in a timely manner • Perceived delays in the delivery of care

42. ISMP Survey on Workplace Intimidation (survey & results) http://www.ismp.org/s/survey0311.htm

43. CHALLENGE #2 • To create an institutional framework that identifies expected behavior at all levels

44. RECOMMENDATIONS: • Re-examine the institution’s mission statement and include a statement in support of civility in the workplace • Develop value statements that apply to all members of the health care team and emphasize that the institution’s civility program applies to persons at all levels within the organization

45. RECOMMENDATIONS • Develop or revise the existing Code of Conduct or Code of Ethics • Utilize professional code of ethics (AMA or ANA) • Include a statement of purpose that stresses fostering professional responsibility on the part of the individual

46. RECOMMENDATIONS • Assure all employees understand the standards of conduct for the institution • Allow staff to review any documents for their input before the documents are finalized.

47. RECOMMENDATIONS • Add to the patients’ and families’ rights and responsibilities document, the expectation that they will behave in a civil manner (reciprocal respect) • Emphasize the expectation that, while each health care team member has his or her own personal values, when they become part of the organization, their conduct is to reflect the institution’s values as well.

48. CHALLENGE #3 • To define a program and a process that operationalizes this framework of civility

49. RECOMMENDATIONS • Designate a committee (“Civility Board”) to manage the organization-wide multidisciplinary program • Determine membership, roles, authority and process • Define the scope of the programs activities • Describe the mechanism to ensure organization-wide integration of the program

50. RECOMMENDATIONS • Define a clear system for reporting of incidents • Define clear mechanisms for responding to incidents • Differentiate between lack of civility and the need to get things done quickly in an emergency. • Develop a special procedure for immediate response to a critical incident