Assignment: UROLOGIC NURSING.
Assignment: UROLOGIC NURSING.
T he Joint Commission(2008) stated, “Intimi -dating and disruptivebehaviors can foster medical errors, contribute to poor patient satisfaction and to prevent- able adverse outcomes, in crease the cost of care, and cause quali- fied clinicians, administrators and managers to seek new positions in more professional environments” (p. 1). With the new Medicare reimbursement mechanisms for hospitals, these issues of cost, safe- ty, and patient satisfaction become even more crucial to address. Yet various kinds of disruptive behav- iors – incivility, bullying, horizon- tal/lateral violence – still are toler- ated in many health care settings (Rosenstein & O’Daniel, 2005; Wilson, Diedrich, Phelps, & Choi, 2011).
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The majority of clinicians enter their chosen discipline with a strong interest in caring for patients. Nurses’ idealism and professional- ism can be undermined by the allowed presence of individuals who create an unhealthy or even hostile work environment. In this article, the ethical issues and ethical justifications for zero tolerance for these disruptive behaviors are described. After types of disruptive behaviors are defined and the prevalence discussed, the focus will
shift to the ethical issues and justifi- cations for change for the individ- ual nurse and for the health care organization. Four suggested practi- cal change strategies are provided.
Examples of disruptive behav- iors are throwing objects, banging down the telephone receiver, inten- tionally damaging equipment, and exposing patients or staff to contam- inated fluids or equipment. In Figure 1 the types of disruptive behaviors are defined and other key behaviors are outlined. The overlap of behaviors in the literature makes it difficult to separate the individ- ual’s actions into different types, as overlap will be noticed (Read & Laschinger, 2013). However, bully- ing is beyond the ambivalent disre- spect of incivility because it is inten- tional, intense mistreatment that tar- gets particular individuals or groups (e.g., nurses’ aides, novice nurses). Some authors consider these two disruptive behaviors as forms of hor- izontal/lateral violence (Purpora, Blegen, & Stotts, 2012).
Prevalence of Problem
Although the prevalence of var- ious types of disruptive behaviors is unknown, some research suggests the widespread nature of this ethi- cal issue. “A survey on intimidation conducted by the Institute for Safe
Medication Practices found that 40% of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator” (Institute for Safe Medication Practices, 2003, p. 4). Recent reports show 39% of graduates in their first year of prac- tice witnessed bullying (Laschinger, 2011), and 31% experienced bully- ing (Laschinger & Grau, 2012). In a statewide survey of South Carolina nurses on the issue of horizontal violence, more than 85% of respon- dents reported being victims, with experienced nurses often listed as perpetrators (Dulaney & Zager, 2010). Wilson and colleagues (2011) also found 85% of nurses had expe- rienced horizontal/lateral violence.
Disruptive Behaviors are A Violation of the Code of Ethics for Nurses
The Code of Ethics for Nurses (American Nurses Association [ANA], 2001) is the profession’s nonnegotiable ethical standard. Its first three provisions define the most essential values and commit- ments of the nurse, with four inter- pretative statements that are rele- vant to ethical issues surrounding disruptive behaviors. Each will be presented and ethical justification for change presented.
Ethical Issues in the Disruptive Behaviors of Incivility, Bullying, And Horizontal/Lateral Violence Vicki D. Lachman
Vicki D. Lachman, PhD, APRN, MBE, FAAN, is President, V.L. Associates, a Consulting and Coaching Company, Philadelphia, PA. She serves on the American Nurses Association Ethics and Human Rights Advisory Board.
General Clinical Practice
Reprinted from MEDSURG Nursing, 2014, Volume 23, Number 1, pp. 56-58, 60. Reprinted with permission of the publisher, Jannetti Publications, Inc., East Holly Avenue, Box 56, Pitman, NJ 08071-0056; 856-256-2300; FAX 856-589- 7463; Email: msjrnl@ajj.com; Website: www.ajj.com
40 UROLOGIC NURSING / January-February 2015 / Volume 35 Number 1
1.5 Relationships with Colleagues and Others
The principle of respect for per- sons extends to all individuals with whom the nurse interacts. The nurse maintains compas- sionate and caring relationships with colleagues and others with a commitment to fair treatment of individuals, to integrity pre- serving compromise, and to resolving conflict (ANA, 2001, p. 9). This statement further empha-
sizes the standard of conduct pro- hibits any form of harassment or intimidating behavior and the expectation that nurses will value the unique contribution of all indi- viduals. Clearly, statement 1.5 strictly prohibits nurses from engag- ing in incivility, bullying, or hori- zontal/lateral violence.
2.3 Collaboration Because of the complexity of
the health care delivery system, a multidisciplinary approach is need- ed. “By its very nature, collaboration requires mutual trust, recognition, and respect among the health care team, shared decision making about patient care, and open dialogue among all parties…” (ANA, 2001, pp. 10-11). Disruptive behaviors interfere significantly with nurses’ intra-professional cooperation and multidisciplinary partnership.
3.5 Acting on Questionable Practice
Nurses are expected to recog- nize and take action concerning any occurrences “of incompetent, un ethical, illegal, or impaired prac- tice by any member of the health care team…” (ANA, 2001, p. 14).
Further more, nurses are expected to express their concern to the per- sons observed with the question- able practice and, if needed to resolve the situation, direct their concern to an administrator. As the previous two interpretative state- ments indicate, incivility, bullying, and horizontal/lateral violence are considered unethical practice. This interpretative statement also indi- cates the organization’s ethical responsibility to have a well-publi- cized process to address practices that violate the expected code of conduct in the organization.
3.6 Addressing Impaired Practice
This statement views impaired practice as not just substance abuse problems, but any colleagues “ad – versely affected by mental or physi-
Figure 1. Definition and Key Behaviors
Type Definition Key Behaviors Sources
Incivility Lack of respect for others • Psychological in nature • Low-intensity, rude, or
inconsiderate conduct • Unclear intent to harm
target
• Rude comments • Offensive or condescending
language • Name calling • Public criticism • Ethnic or sexual jokes • Screaming • Attacking a person’s
integrity • Disregard for
interdisciplinary input about patient care
Andersson, Pearson, & Wagner, 2001; Felblinger, 2009; Read & Laschinger, 2013
Bullying • Repetitive behavior that happens a minimum of twice a week
• Long-term behavior that continues for a minimum of 6 months
• Targeted person finds self- defense difficult and cannot stop the abuse
• Persistent hostility • Regular verbal attacks • Repeated physical threats • Refusal to assist with duties • Write retaliatory comments
about the nurse to nurse manager
• Taunting the nurse in front of others
• Speaking negatively about the nurse to administrators
Felblinger, 2009; Lutgen- Sandvik, Tracy, & Alberts, 2007; McNamara, 2012; Read & Laschinger, 2013; Tuckey, Dollard, Hosking, & Winefield, 2009
Horizontal/Lateral Violence
“Unkind, discourteous, antagonistic interactions between nurses who work at comparable organizational levels and commonly characterized as divisive backbiting and infighting” (Alspach, 2008, p. 13).
• Complaints shared with others without first discussing with the individual
• Sarcastic comments • Withholding support • Ignoring or discounting
individual’s input • Insulting, condescending,
patronizing behaviors
Alspach, 2008
Assignment: UROLOGIC NURSING.
UROLOGIC NURSING / January-February 2015 / Volume 35 Number 1 41
cal illness or by personal circum- stances” (ANA, 2001, p. 15). This statement also identifies the ethical responsibility of the organization to have workplace polices that support the nurse in the confrontation and the individual who clearly needs help in managing life in a more effec- tive way. Incivility, bullying, and horizontal/lateral violence affect the work climate, job performance, and satisfaction of all who are impacted by such behaviors.
Practical Intervention Strategies
No one solution exists for the complex problem of negative human interaction within the orga- nizational culture. However, the lit- erature suggests ways to prevent and address disruptive behaviors. As an organizational consultant, I often am involved in helping indi- viduals and leaders deal with dis- ruptive behavior and have found these four strategies as crucial.
Standards and Code Of Conduct
The Joint Commission (2008) Sentinel Event Alert “Behaviors that Undermine a Culture of Safety” addresses an organization’s account- ability to develop standards, a code of conduct, and suggestions to elim- inate behaviors that undercut a cul- ture of patient and staff safety. Standards to make a zero tolerance policy work were developed by the American Association of Critical Care Nurses (2004; 2005). The six standards are authentic leadership, skilled communication, true collab- oration, effective decision making, appropriate staffing that matches patient needs and competencies, and meaningful recognition. Au – thentic leaders do not tolerate inci- vility and bullying, as they role- model respectful treatment and see the need for trust between leaders and followers within the organiza- tion (Read & Laschinger, 2013). Abuse will continue unless pro- grams for multidisciplinary skill development are established and actions are taken by administrators to institute and enforce zero-toler- ance policy. Offenders need to be disciplined and victims need sup- port.
Skill Development Most participants in the study
by Wilson and colleagues (2011) had at least a bachelor’s degree in nursing, yet nearly 90% noted diffi- culty confronting someone who was demonstrating horizontal/lateral violence. This lack of skill reflects the importance of conflict resolution training for all in the workplace. Many organizations have developed their own training based on the book Crucial Conver sations: Tools for Talking When the Stakes are High (Patterson, Grenny, McMillan, & Switzler, 2012). Others have sent educators to the trainer certification provided by VitalSmarts® (2014), a well-known training model using this book. In my experience many clinical nurses and nurse leaders lack the needed assertiveness and negotiation skills necessary to deal with disruptive behaviors in the workplace.
Empowerment Structural empowerment pro-
vides nurses with access to four structures: information, opportuni- ties, resources, and support (Lasch – inger, 2008). Empowerment is corre- lated inversely with workplace inci- vility and supervisor incivility in the general nursing population (Laschinger, Leiter, Day, & Gilin, 2009), as well as to bullying among new graduates (Laschinger, Grau, Finnegan, & Wilk, 2010). Acts of incivility and bullying are attempts to take power from others; therefore, structural empowerment is related to lower levels of incivility, bully- ing, and horizontal/lateral violence.
Addressing Practitioner Impairment
How often is substance abuse, ineffective management of stress, or mental illness (specifically person- ality disorders) at the root of the dis- ruptive behavior? In my 35 years of organizational consulting experi- ence, the answer is “very often” (Lachman, 2012). Abusers habitual- ly feel above the workplace rules and policies (McNamara, 2012). They see themselves as deserving special privilege and entitled to behave in their chosen way because of what they perceive as incompe- tent or inefficient behavior of oth-
ers. They are often excellent clini- cians, but they lack insight into how they fail to work well with others. They often respond in a defensive and abusive manner to anyone who challenges their practice, especially when the challenge comes from someone they perceive as beneath them in the organization.
The top-level administrator of this clinician (e.g., CNO or CMO) needs to be involved in resolution of the problem, as abusers will not take seriously any intervention by a person of a lower status. Senior peo- ple in the organization need to be prepared for threats of getting them fired, taking the issue to the Board of Nursing or a local paper, or initi- ating a law suit. These are the tough cases, but the willingness of senior administrators to deal or not deal with these disruptive individuals defines the organizational culture. An ethical culture requires leaders to have the moral courage to address disruptive behavior, regard- less of who is violating the desired code of conduct. Assignment: UROLOGIC NURSING.
Conclusion
Incivility, bullying, and hori- zontal/lateral violence are examples of workplace mistreatment that injure individual nurses and the ethical climate of the organization. When these behaviors are allowed, nurse job satisfaction and even retention are affected. The Code of Ethics for Nurses (ANA, 2001) clear- ly identifies intimidating behaviors as unethical and describes the indi- vidual nurse’s responsibility to not engage in such behaviors. In addi- tion, this Code recognizes the responsibility of nurse leaders to implement and enforce policies, processes, education to correct the disruptive behaviors.
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Assignment: UROLOGIC NURSING.
Assignment: UROLOGIC NURSING.
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