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Building a Culture of Compassion: Behaviors that Threaten PerformanceC

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An Online Continuing Education ActivitySponsored By

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Welcome to

Building a Culture of Compassion:

Behaviors that Threaten Performance

(An Online Continuing Education Activity)CONTINUING EDUCATION INSTRUCTIONSThis educational activity is being offered online and may be completed at any time. Steps for Successful Course CompletionTo earn continuing education credit, the participant must complete the following steps:

1. Read the overview and objectives to ensure consistency with your own learning needs and objectives. At the end of the activity, you will be assessed on the attainment of each objective.

2. Review the content of the activity, paying particular attention to those areas that reflect the objectives.

3. Complete the Test Questions. Missed questions will offer the opportunity to re-read the question and answer choices. You may also revisit relevant content.

4. For additional information on an issue or topic, consult the references.5. To receive credit for this activity complete the evaluation and registration form. 6. A certificate of completion will be available for you to print at the conclusion.

Pfiedler Enterprises will maintain a record of your continuing education credits and provide verification, if necessary, for 7 years. Requests for certificates must be submitted in writing by the learner.

If you have any questions, please call: 720-748-6144.

CONTACT INFORMATION:

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Pfiedler Enterprises, 2170 South Parker Road, Suite 125, Denver, CO 80231www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196

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OVERVIEW It is impossible to deliver compassionate, high-quality patient care when staff members work in an atmosphere of fear and intimidation. Hostile behaviors within work teams, particularly bullying, can result in reduced communication and disruption to teamwork. In the perioperative setting, relatively subtle forms of negative behaviors, such as withholding information or covert intimidation, have the potential to cause serious harm when patient care is impacted. The OR is vulnerable to fostering these activities because of the inherent stress of performing surgery and work demands; in addition, the restriction and isolation of the OR allows negative behaviors to be concealed more easily. The consequences for personnel targeted by these behaviors can include emotional and physical ailments such as anxiety, depression, post-traumatic stress disorder, insomnia, eating disorders, and withdrawal from work. These negative behaviors can impact the organization through decreased productivity, increased sick time, and employee attrition.

This continuing education activity will describe why the perioperative setting is a vulnerable environment and discuss the behaviors that threaten performance. The prevalence of these behaviors in healthcare environments, theories as to their causes, and the impact on individuals, organizations, and patient care outcomes will be discussed. It will conclude with a discussion of strategies to combat these behaviors and some anti-bullying tools for individuals.

OBJECTIVES After completing this continuing nursing education activity, the participant should be able to:

1. Describe some of the reasons the perioperative environment is vulnerable to fostering negative behaviors.

2. List examples of terms used to describe behaviors that undermine a culture of safety and distinguish how bullying differs from some other forms of negative behaviors.

3. Describe the prevalence and causes of horizontal violence and bullying. 4. Identify the impact of negative behaviors on individuals, organizations, and patient

care outcomes. 5. Evaluate strategies to combat negative behaviors and promote a healthy work

environment. 6. Discuss some anti-bullying tools that can be used by an individual confronted with

negative behaviors.

INTENDED AUDIENCE This continuing education activity is intended for perioperative nurses and other healthcare professionals who are interested in learning more about combating behaviors that threaten a culture of safety and compassion in the perioperative setting.

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CREDIT/CREDIT INFORMATION State Board Approval for Nurses Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for 2.0 contact hours.

Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end. Licensees must provide their license numbers for record keeping purposes.

The certificate of course completion issued at the conclusion of this course must be retained in the participant’s records for at least four (4) years as proof of attendance.

RElEASE AND ExpIRATION DATEThis continuing education activity was planned and provided in accordance with accreditation criteria. This material was originally produced in August 2016 and can no longer be used after August 2018 without being updated; therefore, this continuing education activity expires August 2018.

DISClAIMERPfiedler Enterprises does not endorse or promote any commercial product that may be discussed in this activity.

SUppORTFunds to support this activity have been provided by Pfiedler Enterprises.

AUThORS/plANNING COMMITTEE/REVIEWERJulia A. Kneedler, RN, MS, EdD Denver, COProgram Manager/Planning Committee/ReviewerPfiedler Enterprises

Judith I. Pfister, RN, BSN, MBA Denver, COProgram Manager/Planning CommitteePfiedler Enterprises

Susan K. Purcell, MA Littleton, COMedical Writer/Author

Melinda T. Whalen, BSN, RN, CEN Denver, COProgram Manager/ReviewerPfiedler Enterprises

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DISClOSURE OF RElATIONShIpS WITh COMMERCIAl ENTITIES FOR ThOSE IN A pOSITION TO CONTROl CONTENT FOR ThIS ACTIVITy Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control content for an educational activity. Information below is provided to the learner, so that a determination can be made if identified external interests or influences pose potential bias in content, recommendations or conclusions. The intent is full disclosure of those in a position to control content, with a goal of objectivity, balance and scientific rigor in the activity. For additional information regarding Pfiedler Enterprises’ disclosure process, visit our website at: http://www. pfiedlerenterprises.com/disclosure.

Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be presented in this continuing education activity. “Relevant financial relationships” are those in any amount, occurring within the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Activity Authors/ Planning Committee/Reviewer Julia A. Kneedler, EdD, RN No conflict of interest

Judith I. Pfister, MBA, RN No conflict of interest

Susan K. Purcell, MA No conflict of interest

Melinda T. Whalen, BSN, RN, CEN No conflict of interest

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pRIVACy AND CONFIDENTIAlITy pOlICyPfiedler Enterprises is committed to protecting your privacy and following industry best practices and regulations regarding continuing education. The information we collect is never shared for commercial purposes with any other organization. Our privacy and confidentiality policy is covered at our website, www.pfiedlerenterprises.com, and is effective on March 27, 2008.

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INTRODUCTIONHorizontal violence, also known as lateral violence, is a term frequently used to describe a deliberate and harmful behavior demonstrated in the workplace by one employee to another. It is a significant problem in the nursing profession and the perioperative environment has many characteristics that make it vulnerable to fostering negative behaviors. When these behaviors become repeated and persistent, it’s called bullying. These behaviors can increase levels of stress and frustration, impairing concentration, impeding communication flow, and adversely affecting staff relationships and team collaboration. Horizontal violence and bullying behaviors negatively affect patient outcomes, nursing practice, and a facility’s bottom line. The consequences for personnel targeted by these behaviors can include emotional and physical ailments such as anxiety, depression, post-traumatic stress disorder, insomnia, eating disorders, and withdrawal from work.

In 2009, The Joint Commission issued a sentinel alert called “Behaviors that Undermine a Culture of Safety” and promulgated a new leadership standard specifically to address these behaviors. Increasingly, professional organizations, including the Association for periOperative Registered Nurses (AORN), American Nurses Association, American Association of Critical-Care Nurses, and the Center for American Nurses have developed position statements that address bullying and horizontal violence in the work environment. Knowledge of the deleterious effects of this behavior and the tools needed to help stop it can empower nurses to create a more respectful, healthier, and safer workplace environment. Effective implementation of a horizontal violence policy will result in an improved work culture that fosters improved employee job satisfaction, a more cohesive work group, and more effective staff communication, all of which results in an increase in the quality of patient care.

ThE pERIOpERATIVE SETTING – A VUlNERABlE ENVIRONMENTOperating rooms are high-intensity, high-stress environments where decisions must be made quickly and resources are stretched. A daily schedule must be managed while integrating emergency surgeries and dealing with the varied personalities of managers, nurses, physicians, technicians, and support staff. The influence of hierarchical and unbalanced power relationships also can add stress to this already challenging work environment. This can create a daunting situation and tempers can flare, resulting in a host of negative behaviors including interpersonal conflict, sarcasm, verbal and nonverbal aggression, and bullying. The perioperative setting can also foster negative behaviors because of the inherent stress of performing surgery; high patient acuity; a shortage of experienced personnel; work demands; and the restriction and isolation of the OR, which allows negative behaviors to be concealed more easily.1,2

Individually, these behaviors may not mean much or may be attributable to the everyday pressures that can be found in any workplace. But the healthcare workplace is not like any other – it has higher stakes than most and an error can have devastating or even deadly consequences. These negative behaviors can increase levels of stress

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and frustration, impairing concentration, impeding communication flow, and adversely affecting staff relationships and team collaboration. They erode a perioperative team’s ability to trust one another enough to ask tough questions, point out errors, ask for help, or double-check work. As stated by AORN: “Members of a highly functioning perioperative team communicate, collaborate, and respect each other’s role and skill set. A positive work environment encourages safe patient care practices, promotes optimal patient outcomes, and fosters a desirable employment setting.4 It is impossible to deliver compassionate, high-quality patient care when staff members work in an atmosphere of fear and intimidation.

BEhAVIORS ThAT ThREATEN pERFORMANCEThe Joint Commission named its July 9, 2008 Issue 40 Sentinel Event Alert “Behaviors that undermine a culture of safety”.4 In response to this safety threat, effective January 1, 2009, the Joint Commission promulgated a new Leadership Standard (LD.03.01.01) to address “intimidating and disruptive behaviors.” Effective July 1, 2012, the term “disruptive behaviors” was revised to “behaviors that undermine a culture of safety” because of the negative connotation to some healthcare providers, including some who found the term “disruptive” to be ambiguous.5 The Joint Commission cited research demonstrating that negative interpersonal conduct can lead to medical errors, preventable adverse patient outcomes, poor patient satisfaction, increased cost of care, increased malpractice risk, and turnover among professionals who have to deal with the abusive offenders.

The research literature is rich with descriptions of various types of behaviors that undermine a culture of safety. There are many terms used to describe these behaviors, including horizontal violence, lateral violence, disruptive behavior, abuse, relational aggression, incivility, bullying, etc. No matter what it’s called, these behaviors share one common theme, namely that they can cause a breakdown in the relationships among healthcare personnel thereby threatening patient and staff well-being.

Although not a new issue for nursing, horizontal violence has been under increased scrutiny, despite its presence in the literature for the past 20 years.6 Increasingly, professional organizations, including the American Nurses Association (ANA),7 the American Association of Critical-Care Nurses (AACN),8 and the Center for American Nurses9 have developed position statements that address bullying and lateral violence in the work environment. The AORN Position Statement On a Healthy Perioperative Practice Environment specifically addresses the culture of the work environment and the need for respect among peers and other healthcare professionals.10 The Council on Surgical & Perioperative Safety, a multidisciplinary coalition that includes seven professional organizations, has a statement on violence in the workplace that includes recommendations for specific organizational strategies to reduce workplace violence, which addresses not only physical violence but bullying behaviors as well.11

These behaviors include overt and covert actions that are displayed by any healthcare worker and that threaten the performance of the healthcare team.12 When the behaviors occur among those in the same ranks of employment, such as staff nurses, it commonly

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is referred to as horizontal or lateral violence.13 When behavior similar to horizontal violence occurs among healthcare providers from different disciplines (eg, physician-nurse, pharmacist-nurse), some use the term “disruptive behavior” or “aggressive behavior” whereas others still refer to it as horizontal/lateral violence since it involves members of the same workforce team and creates hostility in the workplace. The plethora of terms and lack of clear definitions make it difficult to compare studies.

Most agree that the term bullying refers to repeated, persistent actions of individuals directed towards an employee (or a group of employees), which are intended to intimidate, degrade, humiliate, or undermine; or which create a risk to the health or safety of the employee(s).14 When these same behaviors stem from a group and impact one individual, this behavior is termed mobbing.15

In nursing, a term often used to describe bullying behaviors is “nurses eat their young,” which has come to signify the negative behaviors that seasoned nurses perpetrate against novice nurses, and it has come to be considered a rite of passage, particularly in workplaces where the culture may be so acclimated to hierarchical abuse that it may not be immediately identifiable.16 However, nurses of all ages and levels of experience can be affected by bullying and horizontal violence.17,18,19 For example, a display of competence, initiative, success and a strong sense of personal strength, all which can often be found in an older worker, may make one a target for bullying as adult bullies are often jealous of those with higher qualifications. Likewise, a young nurse who is technically savvy may ridicule a seasoned nurse who has less technical ability.

A good source of examples of negative behaviors that undermine a culture of safety is a questionnaire designed to measure horizontal violence. This particular questionnaire, called the Negative Acts Questionnaire – Revised (NAQ-R)20 has been tested for appropriate reliability and validity and is being used more frequently in research studies.21,22,23 Other questionnaires also exist. The NAQ-R measures how often a participant experiences the following negative behaviors – some overt, and some covert:

• Someone withholding information that affects your performance;• Being humiliated or ridiculed in connection with your work;• Being ordered to do work below your level of competence;• Having key areas of responsibility removed or replaced with more trivial tasks;• Spreading of gossip and rumors about you;• Being ignored or excluded or isolated from others;• Having insulting or offensive remarks made about your person, attitudes, and

private life;• Being shouted at or being the target of spontaneous anger (or rage);• Intimidating behavior, finger-pointing, invasion of personal space, shoving, and

blocking/barring the way;• Hints you should quit your job;• Repeated reminders of your errors or mistakes;• Being ignored or facing a hostile reaction when you approach;

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• Persistent criticism of your work or effort;• Having your opinions and views ignored;• Practical jokes carried out by people you don’t get along with;• Being given tasks with unreasonable or impossible targets or deadlines;• Having allegations made against you;• Excessive monitoring of your work;• Pressure not to claim something you are entitled to: sick or vacation time, travel

expenses;• Being subject of excessive teasing and sarcasm; and• Threats of violence or physical abuse or actual abuse.

pREVAlENCEAs noted by The Joint Commission,24 “the majority of health care professionals enter their chosen discipline for altruistic reasons and have a strong interest in caring for and helping other human beings. The preponderance of these individuals carry out their duties in a manner consistent with this idealism and maintain high levels of professionalism.”

Nevertheless, evidence of horizontal violence is abundant in the nursing workforce, as the following studies report. However, these percentages should be viewed cautiously as horizontal violence is defined and measured differently across studies.25

• Rosenstein and O’Daniel26 studied hospital workers, including medical and nursing staff members, administrators, and other healthcare disciplines. Seventy seven percent (77%) of the participants reported witnessing negative behaviors in physicians and 65% of the participants identified negative behaviors in nurses. These participants witnessed negative behavior by nurses on a daily basis 7% of the time and weekly 21% of the time.

• Hader27 reported a study in which nurses were recognized as displaying negative behaviors more frequently than physicians (51.9% vs. 49%). Unlicensed assistive personnel have also been reported to display these behaviors.28

• The prevalence of horizontal violence has been identified as ranging from 5%-38% in Scandinavian countries, the United Kingdom, and the United States.29,30

• Two Australian studies report 50% and 57% prevalence rates for negative behaviors, and 86.5% of participants in a Turkish study reported experiencing aggressive behaviors at work.31

• Wilson and colleagues32 found that 61.1% of surveyed nurses at a community hospital in the Southwest reported horizontal violence observed between coworkers on their unit and that it extended to persons who work closely with nurses, including physicians (49.1%) and staffing supervisors (26.9%).

• Johnson and Rea33 used the NAQ-R to survey 249 members of the Washington State Emergency Nurses Association and found that 27.3% had experienced workplace bullying in the last 6 months. Most respondents who had been bullied stated that they were bullied by their managers/directors or charge nurses.

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Workplace bullying was significantly associated with intent to leave one’s current job and nursing.

• Simons34 used the NAQ-R to survey 511 newly licensed RNs and found that 31% of respondents reported being bullied and that bullying is a significant determinant in predicting intent to leave the organization.

• Purpora, Blegen, and Stotts,35 using the NAQ-R, reported that 21.1% of a random sample of 175 hospital staff RNs drawn from the California Board of Registered Nursing’s mailing list reported horizontal violence.

• Stagg, Sheridan, Jones, and Speroni36 reported that 28% of nurse respondents had been bullied by a member of nursing leadership.

In 2003, the Institute for Safe Medication Practices (ISMP) conducted a national survey regarding intimidation that indicated disrespectful behaviors were not isolated events. In 2013, ISMP conducted a similar survey to determine how things have changed in the last decade. Unfortunately, the 2013 survey results37 show that bullying, intimidation, and other types of disrespectful behavior remain a problem in the healthcare workplace and continue to erode professional communication. The 2013 survey included 4,884 respondents – more than double the number of 2003 participants. Most were nurses (68%) or pharmacists (14%), but more than 200 physicians and almost 100 quality/risk management staff also participated in the survey. Seventy percent (70%) had more than 10 years of experience. Findings indicated that the most frequent disrespectful behaviors reported were38:

• Negative comments about colleagues (reported by 73% at least once, by 20% often);

• Reluctance or refusal to answer questions or return calls (77% at least once, 13% often);

• Condescending language or demeaning comments (68% at least once, 15% often);

• Impatience with questions or hanging up the phone (69% at least once, 10% often); and

• Reluctance to follow safety practices or work collaboratively (66% at least once, 13% often).

Although physical abuse (7%), throwing objects (18%), insults due to race, religion, or appearance (24%), and shaming or humiliation (46%) were not encountered frequently by most respondents, it was sadly noted that nearly a quarter reported those behaviors were among the top three encountered during the past year.39

CAUSESResearchers’ interest has been piqued about horizontal violence for the past several decades with varying viewpoints on the cause. Some researchers believe this is a direct result of oppressed group behavior, which contends that nurses are an oppressed group who may feel frustrated as they strive to advocate for themselves and their practice in a healthcare system that has historically devalued their contribution to health

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care.40,41 Some researchers suggest that factors such as the stressful hospital work environment42,43,44,45,46 and dysfunctional work relationships47 contribute to the incidence of horizontal violence.48 Still others contend that in order to fully understand and address the behaviors and potential outcomes associated with horizontal violence it is important to look at structures and circuits of power within organizations.49

Individuals are complex and bring experiences from “a number of factors including home life and work experiences; training characteristics; cultural, ethnic, generational, and gender biases; hierarchy and role perceptions; personal values; communication styles; personality disorders; and other current events influencing real time mood, attitude, and actions”50 that contribute to negative behaviors. Abusers often feel that they are above the rules and regulations within a workplace.51,52 These perpetrators may be seasoned veterans who feel privileged or entitled to behave this way and are often seen by others as excellent clinicians despite their behaviors.53 Some perpetrators are individuals who do not always understand the evidence supporting their nursing practice and consequently develop defensive, hostile behavior toward anyone who appears to question their work.54

Some nurses bully others simply because they have a need to be in control of all aspects of the work environment.55 Some bullies may have a personality flaw, such as being shortsighted; stubborn to the extreme of psychopathic tendencies, such as trying to be repulsively charming; have an exaggerated sense of self; and lack the ability to be remorseful or feel guilt over the harm inflicted upon others.56,57,58

Some believe that bullying behaviors persist because of a white wall of silence that often protects the bully.59 In some cases, senior managers ingratiate these behaviors and often protect the bully instead of the victims.60 An important and dangerous factor that supports negative behavior is the nurse’s inability to recognize it, name the behavior, and require that it be corrected; many nurses accept it as “the way things are”.61,62 As stated by Dr. Cynthia Clark, a Professor of Nursing at Boise State University “Bullying is allowed to occur for three reasons: because it can; because it is modeled; and because it is left unchecked”.63

IMpACT ON INDIVIDUAlSAll types of inappropriate behavior degrade the victim, distract from the goals of the organization, and can result in a hostile workplace for the victim and others.64 Burnout is one of the major symptoms seen in nurses working in a hostile environment, but there are other potential deleterious effects to the nurse’s personal and professional life, including frustration, increased job stress and absenteeism, and decreased satisfaction with the job and the profession.65 Nurses who are subjected to considerable stress and frustration begin to have low self-esteem, hold a negative opinion of themselves as nurses and feel inferior to other healthcare professionals.66 Physical symptoms may include weight loss or gain, anorexia, gastrointestinal disorders, cardiac palpitations, headache, elevated blood pressure, sleep disorders, and fatigue.67 Psychological manifestations may include anxiety, depression, insecurity, a decrease in self-esteem,

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substance abuse, and suicidal or homicidal thoughts.68 Post-traumatic stress syndrome has been seen in severe cases.69

The level of distress from psychologically disturbing, inappropriate behaviors was rated as very serious by 57% of seasoned nurses.70 Yet, despite the emotional pain and psychological stress caused by horizontal violence, 50% to 80% of events go unreported.71 New graduates do not report events because they fear retaliation and simply want to fit in.72 Seasoned nurses under report horizontal violence because the offender is often the immediate supervisor or the nurse does not understand the reporting process.73

In 2012, Dumont and colleagues reported that in a recent survey, nurses in the 41-50 years and 51-60 years age groups reported more personal effects from horizontal violence than younger groups.74 Although older nurses may not be the target of the bullying, it may still affect them. Older nurses report distress and humiliation when they witness colleagues behaving badly, so the effects of bullying can be far-reaching.75

IMpACT ON ORGANIZATIONSFailure to adhere to professional responsibilities and engage in acceptable interpersonal behaviors sets the scene for unhealthy workplaces. Frustration, disillusionment, and burnout cause seasoned nurses to abandon their career with 14% of nurses reporting horizontal violence as a major factor in their decision to leave the nursing profession.76,77 Likewise, having a reputation as a negative practice environment makes recruitment for the open positions more difficult. Bullying also is costly to organizations due to decreased nurse productivity, satisfaction, and morale.78,79

Two Danish studies80,81 identified a relationship between bullying and sickness (ie, “sick time”) and staff turnover; these are among the highest economic costs of bullying and horizontal violence that burden healthcare institutions.

Seifert82 reported that Rosenstein83 conducted a multihospital study and found a connection between negative behaviors and the following cost-sensitive issues:

• Increased staff sickness;• Staff turnover (RN replacement costs between $22,000 and more than $64,000)84;• Increased lengths of hospital stay for patients;• Reduced patient satisfaction and facility reputation; and• Increased errors and “never events”85.

IMpACT ON pATIENT CARE OUTCOMESThe immediate risk posed by negative behaviors is a decline in collegiality and support, which can lead to poor staff performance and unsatisfactory patient outcomes. The Joint Commission86 reports that 60% of actual or potential harm to patients can be linked to insufficient communication in healthcare organizations. Greenberg et al87 reviewed the records of 444 surgical malpractice claims and identified 60 never events that resulted from a breakdown in communication and caused harm to the patient. Smith surveyed 853 perioperative nurses and was able to identify statistically significant relations between

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exposure to bullying and an increase in the number of adverse patient care never events in the perioperative setting including surgery on the wrong patient and retained surgical items.88

Communication decreases when individuals feel too intimidated to communicate with members of the healthcare team who are known instigators of these negative behaviors.89,90 Rosenstein and O’Daniel91,92 reported that doctors and nurses in hospitals perceive that disruptive behavior, such as use of rude tone of voice or threatening body language, decreases their communication.

If an environment is hostile, quality patient care and safety can become compromised. If new nurses needing answers about unfamiliar treatments, procedures or drugs receive criticism or are ignored, nurses may deliver care without all the information they need.93,94 Healthcare workers have associated incidences of inappropriate behaviors, such as bullying, with potential or actual errors, specific adverse outcomes, and patient mortality.95 For example, the ECRI Institute96 reported that in a Veterans Health Administration study, 17% of the 1,500 respondents reported patients experiencing “pain or prolonged pain, delays in treatment, misdiagnosis, mistreatment, and death as the result of disruptive behavior in their facility”.

In a 2005 study by Rosenstein and O’Daniel,97 94% of 1,474 respondents said disruptive behavior negatively affects patient outcomes. About 60% were aware of an adverse event that resulted from disruptive behavior, and 78% believed the event could have been prevented. Unstable environments where nurses are subjected to intimidating or threatening behaviors also are associated with patient falls, medication delays, and medication errors.98,99,100,101

Almost half of the 2013 respondents of the Institute for Safe Medication Practices (ISMP) survey102 said their past experiences with intimidation altered the way they handle questions about medication orders. At least once during the year, 33% of respondents had concerns but assumed an order was correct rather than interact with an intimidating prescriber. More than one-third asked another professional to talk to a disrespectful prescriber about an order. Eleven percent reported a medication error that occurred primarily due to intimidation.

In 2013, Hutchinson and Jackson103 reported on a systemic review of the literature published between 1990 and 2011 in order to examine the available evidence of the relationship between various forms of hostile clinician behaviors and patient care. An evaluation of 30 studies led the investigators to conclude that there was support to the claims that hostile clinician behaviors can impact unfavorably upon patient care but that understanding the nature of this relationship in any detail is made difficult due to the variability in study designs and the small number of studies identified to be of high quality.

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STRATEGIES TO COMBAT BEhAVIORS AND pROMOTE A hEAlThy WORK ENVIRONMENTThere is little doubt that negative behavior such as horizontal violence/bullying is a prevalent problem in the profession of nursing and strategies for addressing it vary. The Joint Commission requires hospitals to create and maintain a culture of safety under Standard LD.03.01.01. The Joint Commissions’ Sentinel Event Alert104,105 recommends that healthcare organizations take specific steps to prevent these occurrences, including the following:

• Educate all healthcare team members about professional behavior defined by the organization’s code of conduct.

• Hold all team members accountable for modeling desirable behaviors.• Enforce the code of conduct consistently and equitably.• Establish a comprehensive approach to addressing intimidating and disruptive

behaviors that includes a zero-tolerance policy. Encourage strong involvement and support from physician leadership.

• Reduce fears of retribution against those who report intimidating and disruptive behaviors.

• Empathize with and apologize to patients and families who are involved in or witness intimidating or disruptive behaviors.

• Determine how and when disciplinary actions should begin.• Develop a system to detect and receive reports of unprofessional behavior.• Use non-confrontational interaction strategies to address intimidating and

disruptive behaviors within the context of an organizational commitment to the health and well-being of all staff and patients.

But which strategies for implementing a horizontal violence prevention program are really effective? The evidence suggests that horizontal violence policies exist in most facilities only to comply with the standards of accrediting agencies and does not indicate effective implementation of these policies.106

Effective MethodsIn 2013, Coursey and colleagues107 reported on the use of an evidence-based approach to locate and appraise evidence about how to effectively implement horizontal violence policies. They evaluated 12 evidence sources, including some that pertained to successful implementation of policies other than those regarding horizontal violence. The evidence suggests that horizontal violence policies exist in most facilities only to comply with the standards of accrediting agencies and does not indicate effective implementation of these policies. Overall, the evidence somewhat supported the following interventions for successfully implementing a horizontal violence policy:

• Changing behavior in ways to encourage a culture that supports horizontal violence policies:

○ Demonstrate that feedback, both from administrators to staff and from staff to administrators, serves as a stimulus for improvement.

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○ Use education to strengthen coping skills for nurses who deal with negative behaviors. Griffin108 showed that cognitive rehearsal is an effective method to address horizontal violence; participants rehearsed responses to 10 common negative behaviors and were given a laminated card with responses to various scenarios. One year after the training, more than 95% of the participants reported that they saw horizontal violence occur on a variety of nursing units, and approximately half said the behavior was directed at them. Surprisingly, 100% of the participants said they confronted the perpetrator and that the negative behavior stopped.

• Involving nursing administration with nursing personnel frequently and

consistently, including in matters relating to horizontal violence: ○ Staff members must perceive administrators as actively participating in daily activities in the workplace for a horizontal violence policy to be effective. Active involvement helps the administrators find out about behavioral problems and also helps them to be a part of the solution when problems are observed and reported.

○ Managerial leadership aimed at improving the quality of the work environment sends a message to the staff that the leaders are committed to maintaining certain standards on the nursing units. Managers should create a work environment in which everyone is expected to behave with courtesy and respect.

• Intentionally changing policy and the environment:

○ The evidence emphasized the importance of the workplace culture. Individuals and groups involved in setting clinical policy are part of a highly complex network of social relationships that affect their practice. While working together, the teams develop relational skills that improve patient care through better communication.

○ Use of “best practice council” to legislate and standardize practice change across the hospital by using evidence of best practice, which was documented in the narrative review as an effective method of policy implementation. These policies may include those that address horizontal violence. The success of professional communities can be attributed to clear directions, an aggressive timeline, interventions specific to the situation and environment, and to the short-term commitment required of the participants.

• Implementing multiple interventions simultaneously that may not be effective

when used alone: ○ Some interventions (ie, audit and feedback, local consensus processes, marketing, reminders) may not be effective when used alone but may be effective when used in combination. Audit and feedback is a measuring performance of clinicians (such as in terms of patient outcomes) over a specific period of time and reporting that performance to the clinicians. The local consensus process includes involving local health care professionals.

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○ Administrators play a key role in marketing the institution’s commitment to decrease horizontal violence to the nursing staff members.

Ineffective MethodsIn their review, Coursey and colleagues109 noted that some strategies for policy implementation were not supported by the evidence. Zero tolerance policies and passive dissemination of information are not likely to promote implementation of horizontal violence policies.

• Policy makers are abandoning the concept of relying solely on zero tolerance policies. The focus is now on prevention in the form of the development of best practices in the areas of anticipating violent incidents, de-escalation techniques, and improved training in how to manage incidents when they occur.

• Passive dissemination of information was generally ineffective in altering practices, regardless of the importance of the policy subject matter. Policy makers are intensifying their focus on development of best practices to manage horizontal violence incidents when these incidents occur. Better use of empathetic communication, active listening, and improved assessment techniques regarding people’s emotional responses to the situations in which they find themselves might help defuse many incidents before they occur.

Anti-Bullying ToolsIn a 2012 paper entitled “Incivility in Nursing: Unsafe Nurse, Unsafe Patients”, McNamara recommends that nurses arm themselves with what she calls “anti-bullying tools”. These tools can help the individual nurse prepare for being confronted with inappropriate behavior and are described below.110

• Tool One: Use an Organization’s Resources ○ Be familiar with the organization’s conduct policy, which should support “zero tolerance” for abusive behaviors or, at a minimum, it should describe acceptable and unacceptable behaviors.

○ Understand the process for managing unacceptable behaviors and followup reporting.

• Tool Two: Become Educated ○ Learn about horizontal violence, conflict resolution, communication methods, intergenerational or gender conflict assertiveness training, team training, or other behavioral techniques to confront abusers.

○ Use pre-rehearsed responses to negative remarks. Sometimes a simple “I don’t think that is appropriate” works.

○ Use scripted cue cards. The American Nurses Association offers “Tip Cards: Bullying in the Workplace”111 that identify behaviors on one side and effective responses to such behavior on the reverse.

○ Use Griffin’s cognitive rehearsal method.112 She developed it as a shield against horizontal violence for use by newly hired nurses, who spent two

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hours learning to recognize horizontal violence and then practiced techniques to confront it. Participants were given cue cards to use when they were experiencing the various scenarios. Examples of constructive responses on the cards for each of the 10 behaviors Griffin identified as horizontal violence are listed below:

9 Nonverbal innuendo – I sense (I see) from your facial expressions that there may be something you wanted to say to me. It’s OK to speak directly to me.

9 Verbal affront – The individuals I learn the most from are clearer in their directions and feedback. Is there some way we can structure this type of situation?

9 Undermining activities – When something happens that is “different” or “contrary” to what I understood, it leaves me with questions. Help me understand how this situation may have happened.

9 Withholding information – It is my understanding that there was (is) more information available regarding the situation, and I believe if I had known that (more), it would (will) affect how I learn.

9 Sabotage – There is more to this situation than meets the eye. Could “you and I’ (whatever, whoever) meet in private and explore what happened?

9 Infighting – Always avoid unprofessional discussion in nonprivate places. This is not the time or place. Please stop (physically walk away or move to a neutral spot).

9 Scapegoating – I don’t think that is the right connection. 9 Backstabbing – I don’t feel right talking about him/her/the situation when I

wasn’t there or don’t know the facts. Have you spoken to him/her? 9 Failure to respect privacy – It bothers me to talk about that without his/her

permission or I only overheard that – it shouldn’t be repeated. 9 Broken confidences – Wasn’t that said in confidence? Or that sounds like

information that should remain confidential. ○ Offer to present an inservice program on the subject. Self-awareness exercises, role playing, or small focus groups can be valuable tools.

○ Request education on solutions to horizontal violence in education needs surveys.

• Tool Three: Model Appropriate Behavior ○ Set the tone with an attitude of mutual respect and solidarity, creating an environment where colleagues are free to question each other and each other’s practice.

○ Always focus on how the behavior affects the patient. ○ Use the team briefing and debriefing time to clarify any professional issues that needs to be communicated.

○ Do not try to rationalize or defend personal behavior in an interaction with a bully unless this is necessary. Walk away if necessary or solicit help from an objective third party.

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○ Use the organization’s employee assistance program, seek victim counseling, or recommend it to individuals as a constructive way to address abusive behavior.

○ Maintain clinical competence and help others to gain competence as a means to becoming a secure member of the team. Competence affects team members’ trust and respect for one another.

• Tool Four: Do Not Allow Disruptive Behavior to Go Unchecked ○ Address negative behaviors in real time, if at all possible. If patient care is affected, state how the abuser’s behavior is affecting patient care at the time. It may be that the abuser’s behavior is delaying care or diverting attention from preparing for a patient’s surgery. During a surgical procedure, this behavior may distract from concentrating on patient assessment and care.

○ If troubled by repeated bullying, document the behavior (eg, keep a journal describing the behavior, its affects, and any witnesses), sort through the facts, leave emotion out of the documentation, and take action by reporting it to a manager, using an incident report or hotline, or reporting it to the human resources department.

○ If a victim choses to leave an employment position because of a hostile environment, he or she should schedule an exit interview with the head of human resources and be honest and truthful in identifying what has occurred.

SUMMARyAs nurses promote health in their patients, they must also promote health in themselves and one another. Creating a workplace that manifests a culture of compassion begins with mutual respect among all team members. Such a work environment has no room for hostile behaviors that can increase levels of stress and frustration, impairing concentration, impeding communication flow, and adversely affecting staff relationships and team collaboration. Perioperative settings are, by nature, high-stress environments where an error can have devastating or even deadly consequences. Horizontal violence and bullying behaviors negatively affect patient outcomes, nursing practice, and a facility’s bottom line. Knowledge of the deleterious effects of this behavior and the tools needed to help stop it can empower nurses to create a more respectful, healthier, and safer workplace environment. The ultimate outcome of the effective implementation of a horizontal violence policy is the promotion of safer patient care through an improved work culture that fosters improved employee job satisfaction, a more cohesive work group, and more effective staff communication, all of which results in improved quality of patient care.

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GlOSSARyBullying Repeated and persistent actions of individuals

directed towards an employee (or a group of employees), which are intended to intimidate, degrade, humiliate, or undermine an individual.

Covert Concealed, hidden, furtive.

horizontal Violence Behavior directed by one member of a team toward another that harms, disrespects and devalues the worth of the recipient while denying them their basic human rights. Also called lateral violence, verbal abuse, incivility, relational aggression, etc.

Mobbing Bullying by a group of individuals toward a single employee.

Overt Not hidden or secret; expressed in a very open way.

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