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"It takes two to tango"

Incivility in nursing education

Cassie Eckerle

on 13 September 2012

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Transcript of "It takes two to tango"

"It Takes Two
to Tango" Taking a Stand:
Steps to Stop Student Incivility
1. Identify and define at least two student incivility and strategies or tools, and use to defuse these situations

2. Feel a level of empowerment and be active as a motivator and agent of change in situations of incivility “Lateral violence that occurs when two people are victims of a “situation of dominance.”

Due to the perceived oppression, the two individuals turn on each other instead of attempting to confront or deal with the situation causing the oppression What is incivility? Harassment
Any form of unwanted behavior that may range from unpleasant remarks to physical violence (Pontus, 2011)
Involves a person bring treated differently, and in particular, less favorably because of gender, race, sexual orientation, or ability (Pontus, 2011)
“repeated, offensive, abusive, intimidating, or insulting behaviors; abuse of power; or unfair sanctions that make recipients feel humiliated, vulnerable, or threatened, thus creating stress and undermining their self confidence (Crabbs & Smith, 2011)” Subsets of Lateral Violence Incivility Bullying Harassment Scapegoating Backstabbing Broken Confidence Nonverbal Innuendo Verbal Affront Undermining Activities Withholding Information Sabotage Infighting Discrimination Objectives Disrespect Privacy Civility Incivility (cc) photo by medhead on Flickr Stress Anxiety Attitude In 2004 the AACN identified 6 essential standards, one which is
skilled communication, to offset behavior that leads to lateral violence. In 2008, the Joint Commission mandated that organizations develop and implement processes to offset lateral violence by: enforcing a code of conduct teaching employees effective communication skills supporting staff members affected by bullying
(Griffin, 2011) The IOM encouraged the
creation of cultures of safety
within all health care organizations. Predisposing Factors (Johnston, Phanhtharath, & Jackson, 2009)

One study found the top three places for lateral violence to occur was the intensive care unit, emergency departments, and medical-surgical units.
Why is this? Higher stress and faster pace
(Johnston, Phanhtharath, & Jackson, 2009) Non-traditional Health
Stressors Employed "Societal Pressure" New Position of Employment
Transfer into Career or Position http://empoweringwellnessnow.com/ Headache, Dizziness, ADD/ADHD, Anxiety
Irritability & Anger, Panic Disorder Grinding teeth, Tension in jaw Increased Heart Rate, Strokes, Heart Disease,
Hypertension, Diabetes 1&2, Arrythmias IBS, Abdominal Pain, Digestive Disorder Weight Gain and Obesity Insomnia, Emotional and Behavioral Problems, Immune System Dysfunction, Asthma, Ulcers, Depression, Paranoia Muscle Tension,
Fibromyalgia Self-doubt
Aches and pains
Impaired relationships
Rise in Sick Days
Memory dysfunctions Impact in Workplace/Institution Impaired relationships
Requests for transfers
Cognitive impairment
(Bartholomew, 2006) 60% of new nurse leave their first place of employment within the first 6 months (Embree & White, 2010)
The average voluntary nurse turnover rate in hospitals is around 8.4%
There is an average turnover of 27.1% among first year nurses
Registered nurse turnover costs up to 2 times a nurse’s salary
~$92,000 to recruit, hire, and orient a medical surgical nurse
~$145,000 to recruit, hire, and orient a specialty nurse
(Harter & Moody, 2010) Cost of lateral violence Tools to Overcome Incivility Policy and Practice DESC
Model Oppression Theory Cognition Rehearsal What is cognitive rehearsal?
focus on an individual’s understanding of the connections between cause and effect and between action and the consequences of that action
How does it help?
Allows individuals to stop and not automatically process the event as a personal affront
Individuals learn to respond differently to the potential professionally and personally harmful inferences of lateral violence
(Griffin, 2004) Cognitive Rehearsal 26 out of the 25 new nurses witnessed lateral violence

46% (n=12) of the new nurses stated the lateral violence was directed at them

100% of the new nurses who had been victims of lateral violence confronted individual responsible
All stated it was very hard and emotional to stand up to the perpetrator
In every case, the lateral violence stopped following the new nurses actions Knowledge of lateral violence and behavioral interventions allowed newly licensed nurses to confront and stop lateral violence

Many perpetrators may be unaware how their actions make others feel
(Griffin, 2004) It's Proven “It is important to separate facts from stories because facts do not make us angry-but stories do. Stories are our personal conclusions-our judgments about the person. When our story paints the person as a villain, it stimulates our anger” Crucial Conversations: Broken rules
Lack of support
Poor teamwork
(Moss & Maxfield, 2007) The Silent Treatment study collected data from more than 6,500 nurses and nurse managers from health systems around the United
States during 2010.
Disrespect: 85 percent of respondents say that 10 percent or more of the people they work with are disrespectful and therefore undermine their ability to share concerns or speak up about problems. And yet, only 16 percent have confronted their disrespectful colleague. Crucial Conversations: getting results “ Oppression elicits negative behaviors; silence, a lack of voice, poor self-esteem, and the sublimation of the experience of powerlessness through the internal divisiveness known as horizontal violence.”
-Demarco et al. (2005) Low self-esteem
Low morale Powerlessness and
Frustation Unable
to be
self-assertive Unable to support
one another;
towards peers Conflict work
environment; Unable to trust
self-reliance Unable to
change Stanley/ Martin Applied Model:
The Cycle of Oppressed Group Behavior
and Lateral Violence in Nursing Martin et al, 2008Adapted from DeMarco & Roberts, 2003 Where?

Hospital Accept one’s fair share of the workload
Be cooperative
Don’t denigrate to superiors
Don’t be overly inquisitive about each others’ lives
Don’t engage in conversation about a coworker with another coworker
Don’t criticize publicly
Do repay all debts, favors, and compliment

Adapted from Arglye Chaska, 2001. SLACK Incorporated and The Journal of Continuing Education in Nursing. Develop an organizational process for addressing intimidating and disruptive behaviors.

Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice

Develop and implement a reporting/surveillance system.

Support surveillance with tiered, non-confrontational interventional strategies

Document all attempts to address intimidating and disruptive behaviors. Educate all team members

Hold all team members accountable.

“Zero tolerance”

Medical staff policies

Reducing fear of intimidation or retribution

Policy statements that address disruptive behaviors.

Responding to patients and/or their families who are involved in or witness intimidating and/or disruptive behaviors.

How and when to begin disciplinary actions Divide into groups and using the cognitive rehearsal technique come up with one scenario and discuss among your group. Bartholomew, K. (2006). . In L. Rubenzahl (Ed.), Ending nurse-to-Nurse Hostility: why nurses eat their young and each other (Ch.1). Marblehead, MA: HC Pro.
Crabbs, N., & Smith, C. (2011). From Oppression to Opportunity: Eliminating Lateral Violence and Bullying in the Workplace. MedSurg Matters, 20(2), 8-9.
DeMarco, RF & Roberts SJ (2003). Negative Behaviors in Nursing. American Journal of Nursing, 103(3), 113-116.
Embree, J., & White, Ann. (2010). Concept Analysis: Nurse-to-Nurse Lateral Violence. Nursing Forum, 45(3), 166-173.
Freeland, N. Recognizing generational differences in creating a health work environment [Microsoft Word File].
Griffin, C. (2011). Empowerment Strategies for Medical-Surgical Nurses Dealing with Lateral Violence. MedSurg Matters, 20(5), 4-5.
Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of Continuing Education in Nursing, 35(6), 257-263.
Harter, N., & Moody, C. (2010). The Cost of Lateral Violence: All Pain and No Gain. The South Carolina Nurse, 4.
Johnston, M., Phanhtharath, P., & Jackson, B. (2009). The bullying aspect of workplace violence in nursing. Critical Care Nurse Q, 32. Retrieved from http://www.clutterme.com/users/pa/patriciauthsc/Nursing_and_workplace_violence.pdf
Moss, E., & Maxfield, D. (2007). Crucial conversations for healthcare [How to discuss lack of support, poor teamwork, and disrespect].
Pontus, C., & Scherrer, D. (2011). Is it Lateral violence, bullying, or workplace harassment? Often, it is the same. Massachusetts Nurse, 16-17.
Robertson, J. (2012). Can’t we all just get along? A primer on student incivility in nursing education []. Nursing Education Research, 33(1), 21-26.
(2008). Behaviors that undermine a culture of safety. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_40.PDF Reference Big and.... ... small (Crabbs & Smith, 2011) “Nurses covertly or overtly directing their dissatisfaction inward toward each other, toward themselves, and toward those less powerful than themselves”

(Griffin, 2004)

Overt- name-calling, bickering, fault-finding, backstabbing, criticism, intimidation, gossip, shouting, blaming, raising eyebrows.

Covert- unfair assignments, sarcasm, eye-rolling, ignoring, refusing to help, sighing, sighting, whining, sabotage, isolation, exclusion, fabrication

(Bartholomew, 2006) Eric Kern BSN, RN & Cassie Eckerle BSN, RN
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