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Incivility in Nursing Education: Using The Joint Commission Sentinel Event Alert #40 as a Springboard for Action. Presented by Christopher L. Pate, Ph.D, MPA, CQIA 64 th Annual Convention of the Texas Community College Teachers Association 29 January 2011 San Antonio, Texas. Agenda.

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Incivility in Nursing Education: Using The Joint Commission Sentinel Event Alert #40 as a Springboard for Action

Presented by

Christopher L. Pate, Ph.D, MPA, CQIA

64th Annual Convention of the Texas Community College Teachers Association

29 January 2011

San Antonio, Texas

  • The Joint Commission
    • Role
    • Sentinel Events
    • Sentinel Event Alert #40
  • Definitions
  • Prevalence
  • Incivility in nursing education
  • Mitigation through recommendations and steps described by the Joint Commission
  • Implications for higher education
learning outcomes
Learning Outcomes
  • At the conclusion of this presentation, attendees will be able to:
    • Identify the critical features of Sentinel Event Alert Number 40
    • Describe sentinel events in the context of civility
    • Identify characteristics of the concept of civility in healthcare settings
    • Discuss findings of civility-related studies in US healthcare settings
    • List Joint Commission recommendations for improving the environment of care and reducing workplace aggression
    • Discuss causes and consequences of nursing incivility
    • Understand how organizational activities taken in response to the Joint Commission’s changes in civility-related accreditation standards are compatible with collaborative decision making in institutions of higher education
the joint commission
The Joint Commission
  • The Joint Commission (TJC)
    • Seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value
    • Evaluates and accredits more than 17,000 health care organizations and programs in the United States
    • Independent, not-for-profit organization
    • Nation's oldest and largest standards-setting and accrediting body in healthcare (The Joint Commission, 2009).
  • Focused on all aspects of organizational performance
  • Particular interest and focus on
    • Quality
    • Safety
    • Processes
sentinel events
Sentinel Events
  • Sentinel event defined
    • An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The event is called ‘sentinel’ because it sends a signal or sounds a warning that requires immediate attention (The Joint Commission, 2007)
  • TJC began issuing Sentinel Event alerts in 1998 (McLaughlin, 2008)
sentinel event alert issue 40
Sentinel Event Alert: Issue 40
  • Sentinel Event Alert
    • “Behaviors that undermine a culture of safety” (Joint Commission)
    • Issued July 2008
  • Effective 1 January 2009, as requirement for accreditation
  • Specifically linked to domain of organizational leadership
  • Elements of performance (EP)
    • Hospitals/organizations must have code of conduct that defines acceptable, disruptive and inappropriate behaviors
    • Leaders must create and implement a process for managing disruptive and inappropriate behaviors
sentinel events7
Sentinel Events
  • Four Key Goals of Sentinel Event Policies
    • Positive impact on improving patient care, treatment and services and preventing future occurrences
    • Focus attention on understanding the causes and on changing systems and processes to reduce likelihood of future occurrences
    • Increase knowledge about sentinel events, their causes and strategies for prevention
    • Maintain confidence of the public and accredited organizations in the accreditation process (The Joint Commission, 2007)
undermining culture of safety behaviors and outcomes
Undermining Culture of Safety: Behaviors and Outcomes
  • Relationship between intimidating and disruptive behaviors and outcomes
    • Medical errors
    • Poor patient satisfaction
    • Preventable adverse outcomes
    • Increase in cost of care
    • Retention; clinicians, administrators, managers engage in search for jobs external to the organization
  • Joint Commission, 2011 National Patient Safety Goals
    • #2: Improve staff communication

Source: Joint Commission,

  • Most research on topic conducted outside US (e.g., UK, Australia, Canada)
  • US
    • American College of Physician Executives (2009)
      • Survey of 13K physicians and nurses
      • 98% of respondents reported observation of behavioral problems between physicians and nurses within past year
      • 30% indicated that bad behavior occurs several times year; 30% indicated weekly occurrence; approximately 25% occurring monthly
      • Most common: degrading comments, insults
  • US
    • Agency for Healthcare Research and Quality (AHRQ, US Department of Health and Human Services, 2011)
      • 2008 survey (citing work of Rosenstein & O'Daniel); 100 hospitals
      • 77% of respondents reported observation of physicians engaging in disruptive behavior
      • 65% reported witnessing disruptive behavior by nurses
  • US
    • American Association of Critical Care Nurses (AACN), VitalSmarts (2004 Survey)
      • Focus group of 1700 physicians, nurses, administrators (VitalSmarts, 2005)
      • More than 75% “regularly work with doctors or nurses who are condescending, insulting or rude” (Grenny, 2009, p. 30)
      • About 1/3 of the participants reported that behavior includes name-calling, yelling, and swearing (p. 30)
  • Disruptive behavior
    • Behavior that interferes with effective communication among healthcare providers and negatively impacts performance and outcomes; behavior not supportive of a culture of safety (Agency for Healthcare Research and Quality, 2011; Center for American Nurses, 2008)
  • Culture of safety
    • “characterized by open and respectful communication among all members of the healthcare team in order to provide safe patient care. It is a culture that supports an organizational commitment to continually seeking to improve safety” (Institute of Medicine, as cited in Center for American Nurses, 2008)
  • Incivility
    • Lack of regard for others; violation of workplace norms that promote respectful, interpersonal interaction
    • 3 key features
      • Psychological
      • Low intensity, inconsiderate
      • Ambiguous intent to harm target (Felblinger, 2009, p. 14)
  • Bullying
    • Goes beyond incivility; aggressive, deliberate, psychological or physical (Felblinger, 2009)
    • Behavior that is generally persistent, systematic and ongoing (Task Force on the Prevention of Workplace Bullying, as cited in Center for American Nurses, 2008)
disruptive behaviors and incivility
Disruptive Behaviors and Incivility
  • Behaviors associated with incivility
    • Rude comments
    • Disrespectful verbal attacks
    • Offensive, condescending language
    • Lack of collaboration
    • Disregard for interdisciplinary input about patient care
    • Public criticism
    • Subtle or overt verbal aggression
    • Name calling
    • Withholding critical information (Felblinger, 2009)
disruptive behaviors and incivility15
Disruptive Behaviors and Incivility
  • Behaviors associated with incivility
    • Ethnic slurs or jokes
    • Sexual comments
    • Yelling
    • Screaming
    • Attacking a person’s integrity
    • Requesting input when decisions are already made
    • Superficial listening
    • Lacking empathy
    • Blaming others in front of family members; blaming team members when something goes wrong (Felblinger, 2009)
lateral violence
Lateral Violence
  • Lateral or horizontal violence
    • Nursing defined as nurse-to-nurse aggression
    • “aggressive behavior between nurses on the same power level” (Simons, 2008)
    • Verbal or nonverbal
    • Common forms
lateral violence behaviors
Lateral Violence: Behaviors
  • Common forms
    • Non-verbal innuendo
    • Verbal affront
    • Undermining activities
    • Withholding information
    • Sabotage
    • Infighting
    • Scapegoating
    • Backstabbing
    • Failure to respect privacy; broken confidences (Griffin, as cited in Center for American Nurses, 2008)
workplace bullying
Workplace Bullying
  • Workplace bullying
    • “repeated inappropriate behavior, direct or indirect, whether verbal, physical or otherwise, conducted by one or more persons against another or others, at the place of work and/or in the course of employment, which could reasonably be regarded as undermining the individual’s right to dignity at work” (Task Force on the Prevention of Workplace Bullying, as cited in Center for American Nurses, 2008)
specific types of bullying behaviors in healthcare settings
Specific Types of Bullying Behaviors in Healthcare Settings
  • Verbal abuse
  • Written abuse
  • Physical abuse
  • Intimidation
  • Displays of offensive material (Edwards, O’Connell, 2007, p. 28)
verbal abuse
Verbal Abuse
  • Verbal abuse
    • “disruptive form of behavior involving verbal communication that is associated with horizontal violence” (Center for American Nurses, 2008)
    • “any communication a nurse perceives to be a harsh, condemnatory attack upon herself or himself professionally or personally” (Cox, as cited in Center for American Nurses, 2008)
  • Examples
    • Offensive language or innuendo
    • Language that belittles a person’s abilities
    • Spreading malicious rumors
    • Sexist, racist, or patronizing remarks
    • Inappropriate or intimate questioning (NHS, as cited in Edwards, O’Connell, p. 28)
bullying behaviors in healthcare settings written and physical abuse
Bullying Behaviors in Healthcare Settings: Written and Physical Abuse
  • Written
    • Letters, email, faxes
  • Physical
    • Unwanted physical contact
    • Explicit physical threats or attacks
    • Unnecessary touching or assault
    • Stalking that is related to work, may occur at work or outside of work(NHS, as cited in Edwards, O’Connell, p. 28)
bullying behaviors in healthcare settings intimidation and offensive material
Bullying Behaviors in Healthcare Settings: Intimidation and Offensive Material
  • Intimidation
    • Slander
    • Belittling conduct (e.g., being yelled at)
    • Intrusion by pestering, following
    • Unnecessary closeness
    • Apportioning blame wrongly
  • Offensive material
    • Flags and emblems
    • Badges
    • Graffiti
    • Unnecessary highlighting of differences (NHS, as cited in Edwards, O’Connell, p. 28)
how might this look in practice
How Might this Look in Practice?
root causes
Root Causes
  • Individual factors
    • Learned behavior, “perpetrators of bullying have been bullied themselves” (Paterson et al., as cited in Edwards & O’Connell, 2007)
    • Individual insecurities
    • Stress
    • Individuals lack training on appropriate behavior and expectations
  • Organizational factors
    • Power imbalances between organizational members (nursing as “oppressed group,” Hutchinson, Vickers, Jackson, & Wilkes, 2006, p. 119)
    • Lack of professional training
    • Lack of leadership
    • Organizational demands and stress, “do more with less” mentality, focus on productivity
    • Organizational change and uncertainty (Randle, Stevenson, & Grayling, 2007)
effects on individuals
Effects on Individuals
  • Nurse-to-nurse hostility
    • Anxiety, fear, shock, anger, guilt, vulnerability, humiliation
    • Loss of self-confidence
    • Loss of self-esteem
    • Feeling threatened
    • Developing stress-related illness
    • Contemplating suicide (Leiper as cited in Bartholomew, 2006)
practical recommendations an individual perspective with organizational implications
Practical Recommendations: An Individual Perspective with Organizational Implications
  • Disclosure
  • Knowledge of workplace protections
  • Documentation
  • Being assertive
  • Being empathetic
  • Use open questions
  • Buying time
  • Assertiveness training (Randle, Stevenson, & Grayling, 2007)
what and how to address carefronting
What and How to Address: Carefronting
  • Carefronting (Briles, 2009)
    • When you ________________
    • I felt _____________________
    • Because __________________
    • Was it your intent to _______
    • In the future ______________
    • Are you committed to ______
    • If there is not a change _____
incivility in nursing education
Incivility in Nursing Education
  • Defined:
    • “rude or disruptive behaviors that often result in psychological or physiological distress for the people involved and may progress into threatening situations when left unaddressed” (Clark as cited in Clark & Springer, 2010, p. 320)
    • Faculty and student consequences
      • Disrupted student-faculty relationships
      • Problematic learning environments
      • Increased stress levels for faculty and students (Clark & Springer, 2010)
creating a culture of civility in nursing education
Creating a Culture of Civility in Nursing Education
  • Recognition that both students and faculty have responsibilities
  • Factors contributing to incivility
    • Faculty (high stress, negative attitude of superiority, assumption of “know it all” attitude, arrogance)
    • Students (consumer mentality, refusal to accept responsibility, making excuses, high stress)
    • “faculty and student stress and disparaging attitudes in conjunction with missed, avoided, or poorly managed opportunities for meaningful engagement are major contributions to incivility in nursing education” (Clark as cited in Clark & Springer, 2010, p. 320)
an organizational perspective
An Organizational Perspective
  • Strategies
    • Define the problem
    • Awareness and accountability
    • Organizational and leadership commitment
    • Policies and procedures
    • Staff education
    • Communication/team collaboration skills
    • Reporting policy and follow-through
    • Disruptive behavior policy
    • Address barriers
    • Implement intervention plan (Rosenstein, 2009, p. 332)
specific recommendations from the joint commission
Specific Recommendations from the Joint Commission
  • Education
  • Enforce accountability
    • Consistency in enforcement
    • Model desirable behaviors
  • Development of comprehensive approach (policies/procedures)
    • Zero tolerance for intimidating or disruptive behaviors
    • Alignment of medical/professional staff policies with those of larger organization
    • Reducing fear of retaliation; protecting those who report—make non-retaliation clauses part of policy on addressing disruptive behaviors
    • Responding to patients and families that have witnessed intimidating or disruptive behaviors
    • How and when to begin disciplinary actions

Source: Joint Commission,

specific recommendations from the joint commission32
Specific Recommendations from the Joint Commission
  • Develop process for addressing that uses input from inter-professional team
    • Medical staff
    • Nursing staff
    • Administrators
    • Other employees
  • Provide skills-based training
  • Assessment
  • Develop system of reporting and surveillance
  • Use tiered approach to addressing
  • Conduct all interventions within context of improving organizational commitment to the health and well-being of the staff
  • Document all attempts to address intimidating and disruptive behaviors

Source: Joint Commission,

zero tolerance
Zero Tolerance
  • TJC
    • Good start
    • Needs follow-up with “strong communication that there is zero tolerance for these behaviors, and strong actions when they occur” (Physician Executive, 2009, p. 22)
    • “Implement a no-tolerance policy and enforce it 100% of the time” (p. 22)
  • Empower staff
    • “I am sorry, but you may not speak to me it that tone of voice” (p. 22)
healthcare higher education
Healthcare, Higher Education
  • Many similarities between higher education and healthcare
    • Emphasis on costs
    • Emphasis on output measurement, productivity
    • Increasing accountability
    • Organizational power centers
  • Codes of conduct (faculty, employees, students) necessary but insufficient to address disruptive behaviors
  • Collaboration is necessary
    • Inclusion of groups most likely targeted
    • Appropriate cultural mix
  • Accrediting body involvement and standards
  • Places of rigorous inquiry; health sciences education perfect place to start
  • Recognition of institutions that adopt a robust plan to address intimidating and disruptive behavior
point of contact
Point of Contact
  • Contact info:

Christopher Pate, Ph.D, MPA, CQIA

Department of Radiology

Brooke Army Medical Center

Fort Sam Houston, TX 78234


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  • Bartholomew, K. (2006). Ending nurse-to-nurse hostility: Why nurses eat their young and each other. Marblehead, MA: HCPro, Inc.
  • Briles, J. (2009). Are there saboteurs in your midst? Retrieved January 27, 2011 from
  • Broome, B.A. (2008). Dealing with sharks and bullies in the workplace. ABNF Journal, 19(1), 28 – 30.
  • Center for American Nurses (2008). Lateral violence and bullying in the workplace. Retrieved August 15, 2009 from
  • Clark, C.M., & Springer, P.J. (2010). Academic nurse leaders’ role in fostering a culture of civility in nursing education. Journal of Nursing Education, 49(6), 319 – 325.
  • Edwards, S.L., & O’Connell, C.F. (2007). Exploring bullying: Implications for nurse educators. Nurse Education in Practice, 7(1), 26 – 35.
  • Felblinger, D.M. (2009). Bullying, incivility, and disruptive behaviors in the healthcare setting: Identification, impact, and intervention. Frontiers of Health Services Management, 25(4), 13 – 23.
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Johnson, C. (2009). Bad blood: Doctor-nurse behavior problems impact patient care. Physician-Executive, 35(6), 6 – 11.

McLaughlin, S. (2008). Historical perspective: The joint commission’s growing role in the environment of care. Health Facilities Management, 21(4), 43 – 45.

Randle, J., Stevenson, K., & Grayling, I. (2007). Reducing workplace bullying in healthcare organizations. Nursing Standard, 21(22), 49 – 56.

Rosenstein, A.H. (2009). Disruptive behaviour and its impact on communication efficiency and patient care. Journal of Communication in Healthcare, 2(4), 328 – 340.

Sheridan-Leos, N. (2008). Understanding lateral violence in nursing. Clinical Journal of Oncology Nursing, 12(3), 399 – 403.

Simon, S.L. (2008). Mission (im)possible? Nurse civility in the NICU. Neonatal Network, 27(2), 141 – 142.

The Joint Commission (2009). Facts about the Joint Commission. Retrieved November 16, 2009 from

The Joint Commission (2008). Sentinel event alert, Issue 40. Retrieved August 15, 2009 from

The Joint Commission (2007). Sentinel events policies and procedures. Retrieved August 15, 2009 from

VitalSmarts. (2005). Media advisory: Panel examines harmful communication gaps in healthcare system and provides prescription for change. Retrieved January 28, 2011 from